Provider Demographics
NPI:1093092033
Name:DAVIS, JESSICA R (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:202 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1334
Mailing Address - Country:US
Mailing Address - Phone:304-647-4411
Mailing Address - Fax:304-647-6552
Practice Address - Street 1:202 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1334
Practice Address - Country:US
Practice Address - Phone:304-647-4411
Practice Address - Fax:304-647-6552
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV60285367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1093092033Medicaid
WV3810021661Medicaid
WVQ37710AMedicare PIN