Healthcare Provider Details

I. General information

NPI: 1184589848
Provider Name (Legal Business Name): KATHERINE LAKE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4337 E MAIN ST STE 202
FARMINGTON NM
87402-8634
US

IV. Provider business mailing address

4337 E MAIN ST STE 202
FARMINGTON NM
87402-8634
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-1623
  • Fax:
Mailing address:
  • Phone: 505-326-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number87154
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: