Doctor Name: | ELYSE E LAKE |
NPI Number: | 1063721611 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | N.P. |
License Number: | 6168554-8900 |
Business Practice Address: | 3354 W 7800 S West Jordan, UT - 840884506 |
Business Phone Number: | 8012822677 |
Business Fax Number: | 8012822050 |
Mailing Address: | 3354 West 7800 South, WEST JORDAN |
State: | UT |
Postal Code: | 84088 |
Phone Number: | 8012822677 |
Fax Number: | 8012822050 |
NPI Enumeration Date: | 09/30/2010 |
NPI Last Update Date: | 10/07/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | 6168554-8900 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | UT |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |