Healthcare Provider Details

I. General information

NPI: 1104839414
Provider Name (Legal Business Name): DENISE LACK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MISSION BLVD SUITE 2600
JACKSON CA
95642-2536
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-1722
  • Fax: 209-257-1726
Mailing address:
  • Phone: 855-771-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN392072
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: