Provider Demographics
NPI:1447795935
Name:DAVIS, DENISE KATRINA
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:KATRINA
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 1:43 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2444
Mailing Address - Country:US
Mailing Address - Phone:618-201-2925
Mailing Address - Fax:
Practice Address - Street 1:43 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2444
Practice Address - Country:US
Practice Address - Phone:618-201-2925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.121699164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse