Provider Demographics
NPI:1053147785
Name:LACKEN, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:LACKEN
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 1:532 LAFAYETTE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-4411
Mailing Address - Country:US
Mailing Address - Phone:973-795-4554
Mailing Address - Fax:973-940-0399
Practice Address - Street 1:225 ROUTE 23
Practice Address - Street 2:SUITE 1C
Practice Address - City:HAMBURG
Practice Address - State:NJ
Practice Address - Zip Code:07419
Practice Address - Country:US
Practice Address - Phone:973-209-1550
Practice Address - Fax:973-209-4832
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15125800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily