Provider Demographics
NPI:1205590601
Name:LAKE, REBECCA A (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:LAKE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10770 COLUMBIA PIKE STE 300
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4439
Mailing Address - Country:US
Mailing Address - Phone:301-304-7858
Mailing Address - Fax:
Practice Address - Street 1:10770 COLUMBIA PIKE STE 300
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4439
Practice Address - Country:US
Practice Address - Phone:240-452-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD86113932133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered