Provider Demographics
NPI:1275284937
Name:DAVIS, CHARISMA
Entity Type:Individual
Prefix:
First Name:CHARISMA
Middle Name:
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 1:5721 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64130-3713
Mailing Address - Country:US
Mailing Address - Phone:816-223-9102
Mailing Address - Fax:
Practice Address - Street 1:4100 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5082
Practice Address - Country:US
Practice Address - Phone:913-758-6245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer