Provider Demographics
NPI:1326343377
Name:DAVIS, CONSUELO (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CONSUELO
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:HADLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12835-2100
Mailing Address - Country:US
Mailing Address - Phone:518-879-6294
Mailing Address - Fax:
Practice Address - Street 1:88 RIDGE ST RM 109
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3621
Practice Address - Country:US
Practice Address - Phone:518-879-6294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0202001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist