MEDICARE: CHRISTINA LACK FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	0024176541	VA
2	363LF0000X	Family Nurse Practitioner	0024176541	VA

General Provider Information

NPI Number	:	1053892844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA LACK FNP-C

Provider Business Mailing Address
First Line	:	1208 N 37TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-7716
Country	:	US
Telephone Number	:	540-809-5404
Fax Number	:

Provider Business Practice Location Address
First Line	:	5855 BREMO RD STE 208
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-1922
Country	:	US
Telephone Number	:	804-287-7574
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2018
Last Update Date	:	10/22/2024

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Directions to “ CHRISTINA LACK FNP-C” Practice Location

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