Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 25MA08177800 | NJ |
N | 207P00000X | Emergency Physician | MD21481 | ME |
NPI | 1003952375 |
---|---|
Provider Name | Dr. Dianah Thelma Lake |
First Address | Bloomfield, NJ 07003-4414 |
Second Address | Bronx, NY 10461-1138 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 04/05/2017 |