Provider Demographics
NPI:1073772513
Name:DAVIS, MARY RUTH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RUTH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 SARANAC AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-1931
Mailing Address - Country:US
Mailing Address - Phone:716-874-2155
Mailing Address - Fax:
Practice Address - Street 1:207 SARANAC AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14216-1931
Practice Address - Country:US
Practice Address - Phone:716-874-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2789621164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02769657Medicaid