Provider Demographics
NPI:1053419150
Name:LAKE, JANICE (TECH)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 GUS THOMASSON ROAD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2226
Mailing Address - Country:US
Mailing Address - Phone:972-682-0484
Mailing Address - Fax:214-221-5600
Practice Address - Street 1:4124 GUS THOMASSON ROAD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2226
Practice Address - Country:US
Practice Address - Phone:972-682-0484
Practice Address - Fax:214-221-5600
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2471C3402X, 2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX459840OtherBCBS
TX459840Medicare PIN