Provider Demographics
NPI:1316012925
Name:DAVIS, JOAN A (RD LMNT)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-6310
Mailing Address - Country:US
Mailing Address - Phone:402-841-9665
Mailing Address - Fax:
Practice Address - Street 1:809 S. 13TH STREET
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3261
Practice Address - Country:US
Practice Address - Phone:402-379-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE368133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47079687563Medicaid
NEP56623Medicare UPIN
NE099235001Medicare PIN