Healthcare Provider Details

I. General information

NPI: 1255865952
Provider Name (Legal Business Name): STEPHANIE ANN LAKE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE A WEBER DO

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 12/22/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 HARVARD BLVD
DAYTON OH
45406-4543
US

IV. Provider business mailing address

PO BOX 933432
CLEVELAND OH
44193-0039
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-4000
  • Fax: 937-641-4500
Mailing address:
  • Phone: 937-641-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.013785
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: