Provider Demographics
NPI:1538796867
Name:LAKE, ELIZABETH ANN (CLC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:LAKE
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:WIDDEKIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:KREMLIN
Mailing Address - State:MT
Mailing Address - Zip Code:59532-0061
Mailing Address - Country:US
Mailing Address - Phone:406-344-3140
Mailing Address - Fax:
Practice Address - Street 1:20 3RD ST W
Practice Address - Street 2:
Practice Address - City:KREMLIN
Practice Address - State:MT
Practice Address - Zip Code:59532-7708
Practice Address - Country:US
Practice Address - Phone:406-945-0286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAALPP-323072174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty