Provider Demographics
NPI:1164153615
Name:BRENNAN, LACI LUDLUM
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:LUDLUM
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACI
Other - Middle Name:MICHELE
Other - Last Name:LUDLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2008 METACOMET WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:910-508-9288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program