Healthcare Provider Details

I. General information

NPI: 1639976194
Provider Name (Legal Business Name): CAMRYN TAYLOR LAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MILITARY TRL STE 221
JUPITER FL
33458-4813
US

IV. Provider business mailing address

1244 BELFIORE WAY
WINDERMERE FL
34786-8113
US

V. Phone/Fax

Practice location:
  • Phone: 561-625-9695
  • Fax:
Mailing address:
  • Phone: 407-733-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: