Individual
ABIGAIL DIANE LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DNP, PMHNP-BC
Contact information
Practice address
8616 NORTHERN AVE, ROCKFORD, IL 61107-5309
(815) 399-9700
(815) 394-1401
Mailing address
1021 N MULFORD RD, ROCKFORD, IL 61107-3877
Taxonomy
Speciality
Code
Description
License number
State
163WA0400X
Addiction (Substance Use Disorder) Registered Nurse
041404632
IL
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
209.028520
IL
Other
Enumeration date
08/21/2018
Last updated
10/23/2023
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