Provider Demographics
NPI:1083018501
Name:DAVIS, LIESA A (NP-C)
Entity Type:Individual
Prefix:
First Name:LIESA
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:LIESA
Other - Middle Name:A
Other - Last Name:BRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:4640 W ALEXIS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-1182
Mailing Address - Country:US
Mailing Address - Phone:419-474-9324
Mailing Address - Fax:552-870-1608
Practice Address - Street 1:4640 W ALEXIS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-1182
Practice Address - Country:US
Practice Address - Phone:419-474-9324
Practice Address - Fax:855-287-0160
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15925-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112089Medicaid
OHH414300Medicare PIN