Healthcare Provider Details

I. General information

NPI: 1306052246
Provider Name (Legal Business Name): NICOLE LYNN LACZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 11/14/2023
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HIGH ST
NUTLEY NJ
07110-1132
US

IV. Provider business mailing address

777 PASSAIC AVE STE 360
CLIFTON NJ
07012-1800
US

V. Phone/Fax

Practice location:
  • Phone: 973-879-3964
  • Fax: 973-284-0269
Mailing address:
  • Phone: 973-284-0020
  • Fax: 973-284-6310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA08793500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: