Provider Demographics
NPI:1134787088
Name:LAKE, KARI
Entity type:Individual
Prefix:
First Name:KARI
Middle Name:
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 1:5974 N US HIGHWAY 421
Mailing Address - Street 2:
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-9236
Mailing Address - Country:US
Mailing Address - Phone:765-430-9455
Mailing Address - Fax:
Practice Address - Street 1:3050 N ORMSBY BLVD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-8378
Practice Address - Country:US
Practice Address - Phone:765-430-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60979418225X00000X
CA20370225X00000X
OR413311225X00000X
IN31006926A225X00000X
NVOT-2283225X00000X
UT11355364-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist