Provider Demographics
NPI:1275035115
Name:DAVIS, CLAUDETTE ROSE
Entity Type:Individual
Prefix:
First Name:CLAUDETTE
Middle Name:ROSE
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 1:230 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-4020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-4020
Practice Address - Country:US
Practice Address - Phone:845-207-0324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY547093163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY547093Medicaid