| Specialty | Taxonomy Code | |
|---|---|---|
| * | Rural Health | 261QR1300X |
| Nurse Practitioner | 363L00000X |
* Indicates primary specialty
| NPI Number | 1578125647 |
| Legal business name LBN |
FAMILY CLINIC AT THE LAKE PLLC |
| Authorized official | ELLANIKOLE JACKSON - (OWNER) |
| Entity | Organization |
| Organization subpart | No |
| Enumeration date | 06/28/2019 |
| Last updated | 10/14/2019 - About 7 years ago |
| Sole proprietor1 | Not specified |
| Identifiers | n/a |
1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.
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