Provider Demographics
NPI:1629670906
Name:VANACKER, LORI (APN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:VANACKER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:L
Other - Last Name:VANACKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2205 FORGE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4150
Mailing Address - Country:US
Mailing Address - Phone:719-371-0069
Mailing Address - Fax:
Practice Address - Street 1:2205 FORGE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4150
Practice Address - Country:US
Practice Address - Phone:719-371-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0195493163WH0200X
CO0996028-NP207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine