1639665698 NPI number — MARY LACY SMOCK FNP-C

Table of content: MARY LACY SMOCK FNP-C (NPI 1639665698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639665698 NPI number — MARY LACY SMOCK FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMOCK
Provider First Name:
MARY
Provider Middle Name:
LACY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LACY
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639665698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 E PEACOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COCHRAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31014-7847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-934-4988
Provider Business Mailing Address Fax Number:
478-934-4989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 E PEACOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COCHRAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31014-7847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN169989 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)