Provider Demographics
NPI:1356610729
Name:LAKE, MARGARET
Entity type:Individual
Prefix:
First Name:MARGARET
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 1:3130 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2050
Mailing Address - Country:US
Mailing Address - Phone:810-689-8049
Mailing Address - Fax:
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-985-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704252567367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered