Provider Demographics
NPI:1871362848
Name:LAKE, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 GRAY FOX DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-1014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 S RIDGE RD E
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4458
Practice Address - Country:US
Practice Address - Phone:330-703-1819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant