Provider Demographics
NPI:1962966341
Name:LAKE, AMY (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7547
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DR STE 4000
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1774
Practice Address - Country:US
Practice Address - Phone:317-621-7444
Practice Address - Fax:317-621-3150
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008912A363LF0000X
IN28191217A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300024589Medicaid