Provider Demographics
NPI:1720304579
Name:LACKO, NATALIA (RN)
Entity Type:Individual
Prefix:
First Name:NATALIA
Middle Name:
Last Name:LACKO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 MARIN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-7205
Mailing Address - Country:US
Mailing Address - Phone:209-417-9967
Mailing Address - Fax:
Practice Address - Street 1:1112 MARIN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-7205
Practice Address - Country:US
Practice Address - Phone:209-417-9967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA733162163WC0400X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health