Provider Demographics
NPI:1306355466
Name:DAVIS, CARRIE
Entity Type:Individual
Prefix:
First Name:CARRIE
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 1:5065 FORRER RD
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-9703
Mailing Address - Country:US
Mailing Address - Phone:330-641-2795
Mailing Address - Fax:
Practice Address - Street 1:5065 FORRER RD
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-9703
Practice Address - Country:US
Practice Address - Phone:330-641-2795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02263623747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0226362Medicaid