Provider Demographics
NPI:1033604954
Name:DAVIS, KENISHA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KENISHA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 BRANDYWINE RD # 1393
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9307
Mailing Address - Country:US
Mailing Address - Phone:708-655-1482
Mailing Address - Fax:
Practice Address - Street 1:16266 PRINCE DR
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-3233
Practice Address - Country:US
Practice Address - Phone:708-222-7333
Practice Address - Fax:708-221-0501
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277001991363LF0000X, 363LP0808X
IN71008626A363LF0000X, 363LP0808X
AZ251171363LF0000X, 363LP0808X
IL209.017812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health