Provider Demographics
NPI:1225594146
Name:DAVIS, SHONDA MONIQUE
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:MONIQUE
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 1:12416 EXCALIBUR AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2410
Mailing Address - Country:US
Mailing Address - Phone:225-279-7380
Mailing Address - Fax:
Practice Address - Street 1:12416 EXCALIBUR AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2410
Practice Address - Country:US
Practice Address - Phone:225-279-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver