Provider Demographics
NPI:1124704796
Name:LAKE, JAMES BRYAN (FNP-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:BRYAN
Last Name:LAKE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 SEDBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-6008
Mailing Address - Country:US
Mailing Address - Phone:252-916-4443
Mailing Address - Fax:
Practice Address - Street 1:701 DOCTORS DR STE N
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1584
Practice Address - Country:US
Practice Address - Phone:252-559-2200
Practice Address - Fax:252-523-7642
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAKE-2S9JB363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner