Provider Demographics
NPI:1225668213
Name:DAVIS, KEITH (MS, RN, CCRN)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MS, RN, CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ELPASO CT
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-5628
Mailing Address - Country:US
Mailing Address - Phone:631-796-9040
Mailing Address - Fax:
Practice Address - Street 1:10 ELPASO CT
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-5628
Practice Address - Country:US
Practice Address - Phone:631-796-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY636131163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse