Provider Demographics
NPI:1295368595
Name:DAVIS, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
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 1:7112 PAN AMERICAN EAST FWY NE UNIT 97
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9719 CANDELARIA RD NE # 20945
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-9211
Practice Address - Country:US
Practice Address - Phone:505-977-5904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMIHQQ7SPH35Medicaid