Provider Demographics
NPI:1154461770
Name:DAVIS, CHARLES LEE JR (RN)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEE
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5660 INDIAN OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-1104
Mailing Address - Country:US
Mailing Address - Phone:502-636-1659
Mailing Address - Fax:
Practice Address - Street 1:5660 INDIAN OAKS CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1104
Practice Address - Country:US
Practice Address - Phone:502-636-1659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1082037163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse