Provider Demographics
NPI:1093751778
Name:DAVIS, KATHLEEN M (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 EAST NODAWAY
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:MO
Mailing Address - Zip Code:64473-9689
Mailing Address - Country:US
Mailing Address - Phone:660-446-3307
Mailing Address - Fax:660-446-3302
Practice Address - Street 1:401 EAST NODAWAY
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:MO
Practice Address - Zip Code:64473-9689
Practice Address - Country:US
Practice Address - Phone:660-446-3307
Practice Address - Fax:660-446-3302
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO140311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427175302Medicaid
261819Medicare PIN
MO427175302Medicaid
Q41681Medicare UPIN
P00379251Medicare ID - Type UnspecifiedRR MEDICARE #
F29D791AMedicare ID - Type UnspecifiedPART B ST JOSEPH CLINICS
145D791GMedicare ID - Type UnspecifiedPART B BRAYMER
145D791FMedicare ID - Type UnspecifiedPART B HAMILTON CLINIC
145D791CMedicare ID - Type UnspecifiedPART B OREGON CLINIC