Provider Demographics
NPI:1104839414
Name:LACK, DENISE (NP)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:LACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:100 MISSION BLVD
Practice Address - Street 2:SUITE 2600
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2536
Practice Address - Country:US
Practice Address - Phone:209-257-1722
Practice Address - Fax:209-257-1726
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CARN392072363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACX763ZMedicare PIN
CACX763YMedicare PIN