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General NPI Number Information
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NPI Number | 1992900336
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Entity Type | Individual
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Provider Name | JIMMA LANELLE LAKE LPTA
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Gender | Female
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Dates
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Enumeration Date | 06/17/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 112 VINTAGE DR
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City | WAXAHACHIE
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State | TX
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Zip | 75165-6510
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Country | US
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Telephone | 214-632-9075
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Fax | 972-923-0493
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Provider Business Mailing Address
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Address Line | PO BOX 81
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City | RICHLAND
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State | TX
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Zip | 76681-0081
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Country | US
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Telephone | 903-362-4012
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Fax | 903-362-4012
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2012555
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License Number State | TX
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