Basic Information
| Provider Information | |||||||||
| NPI: | 1871164822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKES | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | CLAIRE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 S TUXEDO AVE | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952046219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156862045 | ||||||||
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| Practice Location | |||||||||
| Address1: | 747 CHANNEL STREET | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099444700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2021 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95017948 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.