MEDICARE: AMANDA MARIE LAKE

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1760985147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MARIE LAKE

Provider Business Mailing Address
First Line	:	1300 SUMMERS PL
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-4443
Country	:	US
Telephone Number	:	580-762-4156
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 SUMMERS PL
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-4443
Country	:	US
Telephone Number	:	580-762-4156
Fax Number	:

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

Provider Enumeration Date	:	03/13/2018
Last Update Date	:	03/13/2018

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Directions to “ AMANDA MARIE LAKE ” Practice Location

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