Provider Demographics
NPI:1881946374
Name:LACOMB-DAVIS, MARYLOU (CPNP-PC)
Entity type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:LACOMB-DAVIS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 SAINT SEBASTIAN WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-2613
Mailing Address - Country:US
Mailing Address - Phone:706-721-9847
Mailing Address - Fax:
Practice Address - Street 1:987 SAINT SEBASTIAN WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-2613
Practice Address - Country:US
Practice Address - Phone:706-721-9847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC001077363LP0200X
MDR207282363LP0200X
DCRN960827363LP0200X
VA0024164874363LP0200X
GARN250156363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics