Provider Demographics
NPI:1972690311
Name:LAKE, REBECCA A
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 ROSEBUD PLZ
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-9386
Mailing Address - Country:US
Mailing Address - Phone:304-622-1251
Mailing Address - Fax:304-622-2352
Practice Address - Street 1:612 ROSEBUD PLZ
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-9386
Practice Address - Country:US
Practice Address - Phone:304-622-1251
Practice Address - Fax:304-622-2352
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV024447156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4405720001Medicare ID - Type Unspecified