Provider Demographics
NPI:1093701781
Name:LACY, MARY E (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:LACY
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:5670 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1699
Mailing Address - Country:US
Mailing Address - Phone:404-255-1930
Mailing Address - Fax:404-459-8510
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 1000
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1699
Practice Address - Country:US
Practice Address - Phone:404-255-1930
Practice Address - Fax:404-459-8510
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-08-07
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Provider Licenses
StateLicense IDTaxonomies
GARN131464363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA962062906CMedicaid
GA962062906AMedicaid
GA962062906AMedicaid
GA962062906CMedicaid
GA50BBGTKMedicare PIN