Provider Demographics
NPI:1720007479
Name:MADDEN, LORI KENNEDY (PHD, RN, ACNP)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:KENNEDY
Last Name:MADDEN
Suffix:
Gender:F
Credentials:PHD, RN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6656
Mailing Address - Country:US
Mailing Address - Phone:916-335-9590
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-703-3021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482526163W00000X
CA0120148163WC0200X
CA05-094-00163WN0800X
CA10233363L00000X
CA325935-28363LA2100X
CA474364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3623313Medicaid
CAS68598Medicare UPIN