Healthcare Provider Details

I. General information

NPI: 1720007479
Provider Name (Legal Business Name): LORI KENNEDY MADDEN PHD, RN, ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-2201
US

IV. Provider business mailing address

1350 COMMONS DR
SACRAMENTO CA
95825-6656
US

V. Phone/Fax

Practice location:
  • Phone: 916-703-3021
  • Fax:
Mailing address:
  • Phone: 916-335-9590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10233
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number325935-28
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number474
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number482526
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0120148
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License Number05-094-00
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: