Provider Demographics
NPI:1962072777
Name:DAVIS, LACEY
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 INGLESBY PKWY
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-9117
Mailing Address - Country:US
Mailing Address - Phone:864-433-8443
Mailing Address - Fax:864-433-0495
Practice Address - Street 1:325 INGLESBY PKWY
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9117
Practice Address - Country:US
Practice Address - Phone:864-433-8443
Practice Address - Fax:864-433-0495
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42917164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse