Provider Demographics
NPI:1194378547
Name:DAVIS, KRISTINA NICOLE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S 112TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-1633
Mailing Address - Country:US
Mailing Address - Phone:918-613-9655
Mailing Address - Fax:
Practice Address - Street 1:401 S 112TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-1633
Practice Address - Country:US
Practice Address - Phone:918-613-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator