Provider Demographics
NPI:1225260920
Name:DAVIS, LYNNETTE A (APN)
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-2676
Mailing Address - Country:US
Mailing Address - Phone:309-353-3330
Mailing Address - Fax:309-353-3334
Practice Address - Street 1:2709 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-2676
Practice Address - Country:US
Practice Address - Phone:309-353-3330
Practice Address - Fax:309-353-3334
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007712363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health