Provider Demographics
NPI:1376594713
Name:LAKE, KIMBERLY SUE (DC)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUE
Last Name:LAKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4626 PROGRESS DR STE D
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3485
Mailing Address - Country:US
Mailing Address - Phone:563-344-0777
Mailing Address - Fax:563-344-0888
Practice Address - Street 1:2525 KIMBERLY RD
Practice Address - Street 2:STE #1
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3538
Practice Address - Country:US
Practice Address - Phone:563-344-0777
Practice Address - Fax:563-344-0888
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor