Individual
JERICE LAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2343 W MAIN ST, APT. 2030, MESA, AZ 85201-9003
(340) 642-4597
Mailing address
400 N CORONADO ST APT 3010, CHANDLER, AZ 85224-3207
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
RN198973
AZ
363LP0200X
Pediatric Nurse Practitioner
Primary
264646
AZ
Other
Enumeration date
09/08/2016
Last updated
02/28/2022
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