Provider Demographics
NPI:1154878072
Name:LAKE, JERICE
Entity type:Individual
Prefix:
First Name:JERICE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N CORONADO ST APT 3010
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2343 W MAIN ST
Practice Address - Street 2:APT. 2030
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-9003
Practice Address - Country:US
Practice Address - Phone:340-642-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN198973163W00000X
AZ264646363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse