Provider Demographics
NPI:1164980082
Name:DAVIS, KELLY M (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 FURNACE BROOK RD
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-8258
Mailing Address - Country:US
Mailing Address - Phone:802-733-4883
Mailing Address - Fax:
Practice Address - Street 1:9 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05250-4457
Practice Address - Country:US
Practice Address - Phone:802-733-4883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-10
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0021185163W00000X
VT101.0134392363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse