Healthcare Provider Details

I. General information

NPI: 1871014944
Provider Name (Legal Business Name): DONALD LAKE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PINE GROVE AVE MCIAREN PORT HURON
PORT HURON MI
48060
US

IV. Provider business mailing address

1221 PINE GROVE AVE MCIAREN PORT HURON
PORT HURON MI
48060
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-5000
  • Fax: 810-985-2669
Mailing address:
  • Phone: 810-987-5000
  • Fax: 810-985-2669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704210937
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: