Provider Demographics
NPI:1043211915
Name:DAVIS, JEANNETTE DELRENE (ARNP)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:DELRENE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JEANNETTE
Other - Middle Name:DELRENE
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:525 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5101
Mailing Address - Country:US
Mailing Address - Phone:360-493-7230
Mailing Address - Fax:360-493-4180
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-493-7230
Practice Address - Fax:360-493-4180
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00069915363L00000X
WAAP30003459363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS94119Medicare UPIN
WAGAB12675Medicare PIN