Healthcare Provider Details

I. General information

NPI: 1962634980
Provider Name (Legal Business Name): KATHRYN I. LAKE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8342 US HIGHWAY 301 N
PARRISH FL
34219-8653
US

IV. Provider business mailing address

8342 US HIGHWAY 301 N
PARRISH FL
34219-8653
US

V. Phone/Fax

Practice location:
  • Phone: 941-729-4400
  • Fax: 941-729-4424
Mailing address:
  • Phone: 941-729-4400
  • Fax: 941-729-4424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9476735
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3968
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9476735
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: