Provider Demographics
NPI:1689097214
Name:LACKETT, CARMEN BRIANA
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:BRIANA
Last Name:LACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 DUSK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4304
Mailing Address - Country:US
Mailing Address - Phone:719-499-6231
Mailing Address - Fax:719-452-3579
Practice Address - Street 1:2814 DUSK DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4304
Practice Address - Country:US
Practice Address - Phone:719-499-6231
Practice Address - Fax:719-452-3579
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife