Provider Demographics
NPI:1245777291
Name:DAVIS, KENNETH EARL JR (FNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EARL
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD, BLDG 9250
Mailing Address - Street 2:MARTIN ARMY COMMUNITY HOSPITAL
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-6535
Mailing Address - Country:US
Mailing Address - Phone:762-408-0405
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD, BLDG 9250
Practice Address - Street 2:MARTIN ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-6535
Practice Address - Country:US
Practice Address - Phone:762-408-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily