Provider Demographics
NPI:1205387651
Name:DAVIS, MICHAELA (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-1633
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:1564 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3849
Practice Address - Country:US
Practice Address - Phone:618-542-8702
Practice Address - Fax:618-542-8792
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041445136163W00000X
IL209024151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse