Provider Demographics
NPI:1447253059
Name:LAKE, NATHAN O (RN)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:O
Last Name:LAKE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NW GILMAN BLVD
Mailing Address - Street 2:E103/352
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5395
Mailing Address - Country:US
Mailing Address - Phone:425-269-6466
Mailing Address - Fax:
Practice Address - Street 1:700 NW GILMAN BLVD
Practice Address - Street 2:E103/352
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5395
Practice Address - Country:US
Practice Address - Phone:425-269-6466
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001118197163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse