Provider Demographics
NPI:1376895961
Name:LACKLAND, LAURIE LEIGH (ANP)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:LEIGH
Last Name:LACKLAND
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2104
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86302-2104
Mailing Address - Country:US
Mailing Address - Phone:805-506-1649
Mailing Address - Fax:
Practice Address - Street 1:1065 RUTH ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1729
Practice Address - Country:US
Practice Address - Phone:928-778-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4680363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health