Provider Demographics
NPI:1881413342
Name:LACKORE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LACKORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WORDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 OLD MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:WINN
Mailing Address - State:ME
Mailing Address - Zip Code:04495-5432
Mailing Address - Country:US
Mailing Address - Phone:719-431-1089
Mailing Address - Fax:
Practice Address - Street 1:883 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:ME
Practice Address - Zip Code:04487-4538
Practice Address - Country:US
Practice Address - Phone:719-431-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility