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Individual

MRS. JIMMA LANELLE LAKE

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F
Credential
LPTA

Contact information

Practice address
112 VINTAGE DR, WAXAHACHIE, TX 75165-6510
(214) 632-9075
(972) 923-0493
Mailing address
PO BOX 81, RICHLAND, TX 76681-0081
(903) 362-4012
(903) 362-4012

Taxonomy

Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2012555
TX

Other

Enumeration date
06/17/2007
Last updated
07/08/2007
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