Provider Demographics
NPI:1275241747
Name:LACK, LAURA A (AGPCPNP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:A
Last Name:LACK
Suffix:
Gender:F
Credentials:AGPCPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:14048-2239
Mailing Address - Country:US
Mailing Address - Phone:716-363-6050
Mailing Address - Fax:833-974-1992
Practice Address - Street 1:75 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-2239
Practice Address - Country:US
Practice Address - Phone:716-363-6050
Practice Address - Fax:833-974-1992
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311074363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health