Provider Demographics
NPI:1912693466
Name:LAKE EFFECT HEALING PC
Entity Type:Organization
Organization Name:LAKE EFFECT HEALING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, FNP-BC, PMHNP-BC
Authorized Official - Phone:219-210-8331
Mailing Address - Street 1:613 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3411
Mailing Address - Country:US
Mailing Address - Phone:219-210-8331
Mailing Address - Fax:
Practice Address - Street 1:613 FRANKLIN ST STE C
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3411
Practice Address - Country:US
Practice Address - Phone:317-449-9669
Practice Address - Fax:888-915-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty