Individual
MICHELLE LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1236 E RUSHOLME ST STE 300, DAVENPORT, IA 52803-2484
(800) 382-0707
Mailing address
11 WESTWOOD DR, GENESEO, IL 61254-9584
(309) 507-2367
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
041439972
IL
163W00000X
Registered Nurse
141908
IA
363LA2100X
Acute Care Nurse Practitioner
Primary
H171781
IA
Other
Enumeration date
08/24/2022
Last updated
07/13/2023
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