Provider Demographics
NPI:1235129776
Name:DAVIS, DONNA (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 BRAVO BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3478
Mailing Address - Country:US
Mailing Address - Phone:270-651-2181
Mailing Address - Fax:270-651-2183
Practice Address - Street 1:1507 BRAVO BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3478
Practice Address - Country:US
Practice Address - Phone:270-651-2181
Practice Address - Fax:270-651-2183
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY451156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY451OtherOPTICIAN LICENSE