Healthcare Provider Details

I. General information

NPI: 1639501877
Provider Name (Legal Business Name): CAROLYN PERROTTI LAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 04/26/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 SCRIPPS DR
SACRAMENTO CA
95825-6209
US

IV. Provider business mailing address

1530 FOXRIDGE CIR
AUBURN CA
95603-5953
US

V. Phone/Fax

Practice location:
  • Phone: 916-259-6648
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95003836
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95003836
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12.005412
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: