Provider Demographics
NPI:1073906749
Name:COOK, LACI NICOLE (CPNP)
Entity Type:Individual
Prefix:MS
First Name:LACI
Middle Name:NICOLE
Last Name:COOK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-3145
Mailing Address - Country:US
Mailing Address - Phone:917-748-5073
Mailing Address - Fax:
Practice Address - Street 1:270 UNION AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1823
Practice Address - Country:US
Practice Address - Phone:631-588-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20142655363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics