Provider Demographics
NPI:1902127509
Name:LAKE, BERNADINE VERNETTA (MD)
Entity Type:Individual
Prefix:
First Name:BERNADINE
Middle Name:VERNETTA
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26160 W 12 MILE RD
Mailing Address - Street 2:APT C-33
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1764
Mailing Address - Country:US
Mailing Address - Phone:313-623-7688
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF TENNESSE
Practice Address - Street 2:910 MADISON AVENUE SUITE 1031
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-5364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program