Provider Demographics
NPI:1477175602
Name:DAVIS, SAFYYAH DESEREE (LPN)
Entity Type:Individual
Prefix:MS
First Name:SAFYYAH
Middle Name:DESEREE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:SAFYYAH
Other - Middle Name:DESEREE
Other - Last Name:PRINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1260 MORENA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3889
Mailing Address - Country:US
Mailing Address - Phone:619-398-0355
Mailing Address - Fax:619-389-0350
Practice Address - Street 1:2865 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2411
Practice Address - Country:US
Practice Address - Phone:619-232-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2019020804LPN164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA719792OtherLICENSE VOCATIONAL NURSE
OR2019020804LPNOtherOREGON BOARD OF NURSING