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General NPI Number Information
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NPI Number | 1518675727
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Entity Type | Individual
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Provider Name | MAYA LAKE
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Gender | Female
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Dates
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Enumeration Date | 11/08/2022
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Last Update Date | 11/08/2022
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Provider Practice Location Address
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Address Line | 2053 METROPOLITAN PKWY SW STE A
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City | ATLANTA
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State | GA
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Zip | 30315-5926
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Country | US
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Telephone | 404-600-3830
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Fax |
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Provider Business Mailing Address
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Address Line | 2973 HEADLAND DR SW STE D
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City | ATLANTA
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State | GA
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Zip | 30311-5434
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Country | US
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Telephone | 404-600-3830
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Fax |
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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 | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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