Provider Demographics
NPI:1043395361
Name:DAVIS, KATILYN MARIE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:KATILYN
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 W 23RD ST
Mailing Address - Street 2:STE 130
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1670
Mailing Address - Country:US
Mailing Address - Phone:952-345-3213
Mailing Address - Fax:
Practice Address - Street 1:10617 KYLE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-1249
Practice Address - Country:US
Practice Address - Phone:612-802-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR188521-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology