Provider Demographics
NPI:1093701781
Name:LACY, MARY J (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:LACY
Suffix:
Gender:
Credentials:NP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:310 KENNESTONE HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1120
Mailing Address - Country:US
Mailing Address - Phone:770-793-7856
Mailing Address - Fax:770-793-7856
Practice Address - Street 1:310 KENNESTONE HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1120
Practice Address - Country:US
Practice Address - Phone:770-793-7856
Practice Address - Fax:770-793-7856
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2025-04-17
Deactivation Date:
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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
GA962062906AMedicaid
GA962062906CMedicaid
GA962062906AMedicaid
GA962062906CMedicaid
GA50BBGTKMedicare PIN