Provider Demographics
NPI:1346633112
Name:DAVIS, QUIANA
Entity Type:Individual
Prefix:
First Name:QUIANA
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 1:2478 NORTH 34TH STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2478 NORTH 34TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210
Practice Address - Country:US
Practice Address - Phone:414-324-8903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI313850164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346633112Medicaid