Provider Demographics
NPI:1376769638
Name:DAVIS, DEBRA MOLLIE (RN BSN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:MOLLIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:MOLLIE
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN BSN
Mailing Address - Street 1:587 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61531-1303
Mailing Address - Country:US
Mailing Address - Phone:309-245-2862
Mailing Address - Fax:
Practice Address - Street 1:2079 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554
Practice Address - Country:US
Practice Address - Phone:309-382-2006
Practice Address - Fax:309-382-2007
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management