Provider Demographics
NPI:1225546443
Name:DAVIS, LEQUESOR LYNETTE
Entity Type:Individual
Prefix:
First Name:LEQUESOR
Middle Name:LYNETTE
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 1:1459 WILD BLOSSOM WAY
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7635
Mailing Address - Country:US
Mailing Address - Phone:225-333-9220
Mailing Address - Fax:303-997-9810
Practice Address - Street 1:1459 WILD BLOSSOM WAY
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7635
Practice Address - Country:US
Practice Address - Phone:225-333-9220
Practice Address - Fax:303-997-9810
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO062770743343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)