Healthcare Provider Details

I. General information

NPI: 1902127509
Provider Name (Legal Business Name): BERNADINE VERNETTA LAKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF TENNESSE 910 MADISON AVENUE SUITE 1031
MEMPHIS TN
38163-0001
US

IV. Provider business mailing address

26160 W 12 MILE RD APT C-33
SOUTHFIELD MI
48034-1764
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-5364
  • Fax:
Mailing address:
  • Phone: 313-623-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: