Provider Demographics
NPI:1194468389
Name:DAVIS, KEIRI JENAE (LMBT)
Entity Type:Individual
Prefix:MRS
First Name:KEIRI
Middle Name:JENAE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 BETHESDA PL STE 601B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3314
Mailing Address - Country:US
Mailing Address - Phone:336-464-7731
Mailing Address - Fax:
Practice Address - Street 1:2990 BETHESDA PL STE 601B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3314
Practice Address - Country:US
Practice Address - Phone:336-464-7731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15481225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty