Provider Demographics
NPI:1225320245
Name:DAVIS, PHYLLIS
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
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:PO BOX 772
Mailing Address - Street 2:MINUTECLINIC CREDENTIALING
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-0784
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:401-652-9787
Practice Address - Street 1:183 US HIGHWAY 206 S
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-2402
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-652-9787
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023559363LP0808X
PASP011233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily