Provider Demographics
NPI:1053907261
Name:LAKE, PEARL A
Entity type:Individual
Prefix:MRS
First Name:PEARL
Middle Name:A
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 E MONMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4103
Mailing Address - Country:US
Mailing Address - Phone:267-884-8807
Mailing Address - Fax:215-825-5161
Practice Address - Street 1:2214 S 57TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5705
Practice Address - Country:US
Practice Address - Phone:886-884-8807
Practice Address - Fax:215-825-5161
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA70000634RMA171000000X
PA7000.000000634RMA171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty