Provider Demographics
NPI:1457009144
Name:DAVIS, ROLANDRA
Entity Type:Individual
Prefix:
First Name:ROLANDRA
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 1:536 JUNG BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-1012
Mailing Address - Country:US
Mailing Address - Phone:504-816-0292
Mailing Address - Fax:
Practice Address - Street 1:536 JUNG BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-1012
Practice Address - Country:US
Practice Address - Phone:504-816-0292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006627995172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty