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General NPI Number Information
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NPI Number | 1114552452
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Entity Type | Individual
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Provider Name | KELLEY JOANNE DEVLIN-LAKE RN
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Gender | Female
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Dates
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Enumeration Date | 03/06/2020
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Last Update Date | 03/06/2020
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Provider Practice Location Address
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Address Line | 2426 BUHNE ST
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City | EUREKA
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State | CA
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Zip | 95501-3207
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Country | US
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Telephone | 707-443-4666
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Fax | 707-445-4499
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Provider Business Mailing Address
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Address Line | 1275 8TH ST
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City | ARCATA
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State | CA
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Zip | 95521-5770
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Country | US
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Telephone | 707-826-8633
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Fax | 707-826-8628
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 308172
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License Number State | CA
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