Individual
FAMINDA T LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FAMINDA
Contact information
Practice address
3300 GALLOWS RD, FALLS CHURCH, VA 22042-3307
(703) 776-2632
Mailing address
2343 MERSEYSIDE DR, WOODBRIDGE, VA 22191-6568
(703) 730-9597
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
0001269149
VA
367500000X
Certified Registered Nurse Anesthetist
Primary
0024178894
VA
Other
Enumeration date
12/11/2019
Last updated
03/12/2020
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