Provider Demographics
NPI:1639665698
Name:SMOCK, MARY LACY (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LACY
Last Name:SMOCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:LACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:265 SHERATON BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210
Mailing Address - Country:US
Mailing Address - Phone:478-746-8626
Mailing Address - Fax:478-329-8573
Practice Address - Street 1:265 SHERATON BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:478-746-8626
Practice Address - Fax:478-329-8573
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN169989363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily