Provider Demographics
NPI:1033642046
Name:LACEK, AMANDA LAUREN (RN)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LAUREN
Last Name:LACEK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LAUREN
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7947 NIGHTINGALE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2728
Mailing Address - Country:US
Mailing Address - Phone:210-845-7863
Mailing Address - Fax:
Practice Address - Street 1:7947 NIGHTINGALE WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2728
Practice Address - Country:US
Practice Address - Phone:210-845-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95102040163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse