STACY ELLEN LAKE

FORT WAYNE, IN
NPI1912274663
Entity TypeIndividual
GenderFemale
Sole Proprietor ?No
Primary Taxonomy2255A2300X Specialist/Technologist, Athletic Trainer
(Licence: IN  36000573A)
Enumeration Date2011-11-23
Last Update Date2011-11-23
Business Address
-- STACY ELLEN LAKE ATC
14730 PULVER RD
FORT WAYNE, IN 46845-9629
Phone number: 260-413-6770
Mailing Address
-- STACY ELLEN LAKE ATC
14730 PULVER RD
FORT WAYNE, IN 46845
Phone number: 260-413-6770
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