Individual
STACY ELLEN LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ATC
Contact information
Practice address
14730 PULVER RD, FORT WAYNE, IN 46845-9629
(260) 413-6770
Mailing address
14730 PULVER RD, FORT WAYNE, IN 46845
(260) 413-6770
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
36000573A
IN
Other
Enumeration date
11/23/2011
Last updated
11/23/2011
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