Healthcare Provider Details

I. General information

NPI: 1790621787
Provider Name (Legal Business Name): BRANDY LYNNETTE LAKE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 S HIGHWAY 65
MARSHALL MO
65340-3702
US

IV. Provider business mailing address

2305 S HIGHWAY 65
MARSHALL MO
65340-3702
US

V. Phone/Fax

Practice location:
  • Phone: 660-886-7431
  • Fax:
Mailing address:
  • Phone: 660-831-3292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2026015358
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: