Provider Demographics
NPI:1083886469
Name:DAVIS, JUDY ALICE (MA)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:ALICE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 KAUFMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-6542
Mailing Address - Country:US
Mailing Address - Phone:772-216-8954
Mailing Address - Fax:772-595-6646
Practice Address - Street 1:805 KAUFMAN AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-6542
Practice Address - Country:US
Practice Address - Phone:772-216-8954
Practice Address - Fax:772-595-6646
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46020225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist