MEDICARE: BRENDA KAY LAKE R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	349091	OH

General Provider Information

NPI Number	:	1326384835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA KAY LAKE R.N.

Provider Business Mailing Address
First Line	:	3717 BAY RD
Second Line	:
City	:	ERIE
State	:	MI
Zip	:	48133-9404
Country	:	US
Telephone Number	:	419-297-4629
Fax Number	:	734-723-4001

Provider Business Practice Location Address
First Line	:	3717 BAY RD
Second Line	:
City	:	ERIE
State	:	MI
Zip	:	48133-9404
Country	:	US
Telephone Number	:	419-297-4629
Fax Number	:	734-723-4001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	11/29/2019

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