Provider Demographics
NPI:1033668488
Name:DAVIS-NETTLES, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DAVIS-NETTLES
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:765-453-5696
Mailing Address - Fax:765-455-4323
Practice Address - Street 1:1601 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902
Practice Address - Country:US
Practice Address - Phone:765-453-5696
Practice Address - Fax:765-455-4323
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN174001470237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist