Active NPI
Stacy Ellen Lake, ATC
- Athletic Trainer
- Fort Wayne, IN
National Provider Identifier
1912274663
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 36000573A
- Practice address
- 14730 Pulver Rd
Fort Wayne, IN 46845-9629 - Phone
- (260) 413-6770
- NPI assigned
- Nov 23, 2011
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 36000573A | IN | Primary |
Addresses
Primary practice location
14730 Pulver Rd
Fort Wayne, IN 46845-9629
Mailing address
14730 Pulver Rd
Fort Wayne, IN 46845
Phone (260) 413-6770
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 36000573A | IN | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1322006400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1322006400000",
"number": "1912274663",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "14730 PULVER RD",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "46845",
"telephone_number": "260-413-6770"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "14730 PULVER RD",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "468459629",
"telephone_number": "260-413-6770"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LAKE",
"first_name": "STACY",
"middle_name": "ELLEN",
"credential": "ATC",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2011-11-23",
"last_updated": "2011-11-23",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "IN",
"license": "36000573A",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Wayne, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 23, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.