Provider Demographics
NPI:1427593664
Name:DAVIS, SHANA RICHELLE SARAH (CD)
Entity Type:Individual
Prefix:MS
First Name:SHANA
Middle Name:RICHELLE SARAH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 W TAYLOR ST # 2782
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4623
Mailing Address - Country:US
Mailing Address - Phone:219-208-4586
Mailing Address - Fax:
Practice Address - Street 1:7408 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46323-2921
Practice Address - Country:US
Practice Address - Phone:708-674-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-26
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1427593664Medicaid