Provider Demographics
NPI:1164616280
Name:DAVIS, JANET MARIE (NP)
Entity Type:Individual
Prefix:MS
First Name:JANET
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1777 GREEN BAY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3297
Mailing Address - Country:US
Mailing Address - Phone:847-433-3460
Mailing Address - Fax:847-433-4062
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:858-249-6751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95006617363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK46193Medicare PIN