Provider Demographics
NPI:1639976194
Name:LAKE, CAMRYN TAYLOR
Entity type:Individual
Prefix:
First Name:CAMRYN
Middle Name:TAYLOR
Last Name:LAKE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 BELFIORE WAY
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-8113
Mailing Address - Country:US
Mailing Address - Phone:407-733-4375
Mailing Address - Fax:
Practice Address - Street 1:4600 MILITARY TRL STE 221
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-4813
Practice Address - Country:US
Practice Address - Phone:561-625-9695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical