Basic Information
| Provider Information | |||||||||
| NPI: | 1922510635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE FOREMAN | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | DARLENE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LAKE | ||||||||
| OtherFirstName: | LACEY | ||||||||
| OtherMiddleName: | DARLENE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 117 EDINBORO DR | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7248757632 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3520 ROUTE 130 BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | IRWIN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156421438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247441408 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| LastUpdateDate: | 11/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP018060 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.