Provider Demographics
NPI:1881302321
Name:LAKE, BENJAMIN FRANK (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:FRANK
Last Name:LAKE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 SAINT GERMAIN RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3152
Mailing Address - Country:US
Mailing Address - Phone:805-801-0590
Mailing Address - Fax:
Practice Address - Street 1:917 SAINT GERMAIN RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-3152
Practice Address - Country:US
Practice Address - Phone:207-217-7924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023020363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health