Provider Demographics
NPI:1194179515
Name:DAVIS, NASTASSIA (MSN, RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:NASTASSIA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSN, RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 CENTRAL AVE STE 213
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-3921
Mailing Address - Country:US
Mailing Address - Phone:973-488-7975
Mailing Address - Fax:973-860-2220
Practice Address - Street 1:36 RANDOLPH PL
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4808
Practice Address - Country:US
Practice Address - Phone:914-882-9475
Practice Address - Fax:973-860-2220
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY558884163WL0100X
NJ26NR15908000163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant