Healthcare Provider Details

I. General information

NPI: 1265906242
Provider Name (Legal Business Name): MRS. LACRESHA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 SW C AVE
LAWTON OK
73501-4016
US

IV. Provider business mailing address

317 SW C AVE
LAWTON OK
73501-4016
US

V. Phone/Fax

Practice location:
  • Phone: 580-357-6141
  • Fax:
Mailing address:
  • Phone: 580-250-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number131080
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number320211
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: