Provider Demographics
NPI:1194186833
Name:LAKES DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:LAKES DERMATOLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:712-336-2728
Mailing Address - Street 1:2704 ENTERPRISE AVE
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360
Mailing Address - Country:US
Mailing Address - Phone:712-336-2728
Mailing Address - Fax:712-336-2842
Practice Address - Street 1:2704 ENTERPRISE AVE
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360
Practice Address - Country:US
Practice Address - Phone:712-336-2728
Practice Address - Fax:712-336-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-118055363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1841548161OtherINDIVIDUAL NPI