Provider Demographics
NPI:1528438538
Name:LAKE, DOROTHY NICOLE (CPNP)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:NICOLE
Last Name:LAKE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-1427
Mailing Address - Country:US
Mailing Address - Phone:404-366-3636
Mailing Address - Fax:404-362-0808
Practice Address - Street 1:1561 S HIGHWAY 27
Practice Address - Street 2:UNIT B6 & B7
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-8927
Practice Address - Country:US
Practice Address - Phone:404-366-3636
Practice Address - Fax:404-362-0808
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213402NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics