MEDICARE: CODIE R LAKE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	726518	NY

General Provider Information

NPI Number	:	1144894718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODIE R LAKE RN

Provider Business Mailing Address
First Line	:	2039 NEREID AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-1110
Country	:	US
Telephone Number	:	917-645-6440
Fax Number	:

Provider Business Practice Location Address
First Line	:	2039 NEREID AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-1110
Country	:	US
Telephone Number	:	917-645-6440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2021
Last Update Date	:	05/18/2021

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