MEDICARE: MAKENZIE LAKE

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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	UNSURE	GA

General Provider Information

NPI Number	:	1720942238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAKENZIE LAKE

Provider Business Mailing Address
First Line	:	33 BURGUNDY DR
Second Line	:
City	:	LAKE SAINT LOUIS
State	:	MO
Zip	:	63367-1505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 JESSE HILL JR DR SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30303-3050
Country	:	US
Telephone Number	:	913-669-0877
Fax Number	:

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

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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Directions to “ MAKENZIE LAKE ” Practice Location

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