Provider Demographics
NPI:1669790200
Name:LAKE, KATIE R
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:R
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:R
Other - Last Name:CHEFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 880
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:406-745-4233
Practice Address - Street 1:308 MISSION DRIVE
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59864
Practice Address - Country:US
Practice Address - Phone:406-745-3575
Practice Address - Fax:406-745-4233
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2969247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist