Provider Demographics
NPI:1285862300
Name:DAVIS, BRENDA
Entity Type:Individual
Prefix:MISS
First Name:BRENDA
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 1:111 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-5990
Mailing Address - Country:US
Mailing Address - Phone:219-670-3148
Mailing Address - Fax:219-844-3578
Practice Address - Street 1:111 W 10TH ST
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5990
Practice Address - Country:US
Practice Address - Phone:219-670-3148
Practice Address - Fax:219-844-3578
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28171562A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner