MEDICARE: NORMA LAKE CNP

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	363LF0000X	Family Nurse Practitioner	RN133167 NP08109	OH

General Provider Information

NPI Number	:	1871591032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NORMA LAKE CNP

Provider Business Mailing Address
First Line	:	635 N ERIE ST
Second Line	:	STE 272
City	:	TOLEDO
State	:	OH
Zip	:	43604-5317
Country	:	US
Telephone Number	:	419-517-7600
Fax Number	:	419-517-7598

Provider Business Practice Location Address
First Line	:	4126 N HOLLAND SYLVANIA RD
Second Line	:	SUITE 220
City	:	TOLEDO
State	:	OH
Zip	:	43623-3536
Country	:	US
Telephone Number	:	419-517-7600
Fax Number	:	419-517-7598

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	11/09/2016

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Directions to “ NORMA LAKE CNP” Practice Location

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