Provider Demographics
NPI:1093481582
Name:LACOMB, HEATHER (LPN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LACOMB
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 S POPLAR PL
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-3841
Mailing Address - Country:US
Mailing Address - Phone:918-350-8296
Mailing Address - Fax:
Practice Address - Street 1:27 E ROSS AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066
Practice Address - Country:US
Practice Address - Phone:918-216-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK204320164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse