Basic Information
| Provider Information | |||||||||
| NPI: | 1972978237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OVEREEM | ||||||||
| OtherFirstName: | GRETCHEN | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 NW GARDEN VALLEY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Practice Location | |||||||||
| Address1: | 272 MEDICAL LOOP | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2015 | ||||||||
| LastUpdateDate: | 12/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.