Healthcare Provider Details

I. General information

NPI: 1588912836
Provider Name (Legal Business Name): LACI ANN BURK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 N 3RD AVE STE 210
SANDPOINT ID
83864-1511
US

IV. Provider business mailing address

520 N 3RD AVE
SANDPOINT ID
83864-1507
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-2173
  • Fax:
Mailing address:
  • Phone: 208-263-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-RN-LIC-34875
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-1723A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: