Provider Demographics
NPI:1477633659
Name:DAVIS, LAURIE J (ARNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1166
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-1166
Mailing Address - Country:US
Mailing Address - Phone:425-258-7357
Mailing Address - Fax:425-258-7022
Practice Address - Street 1:420 GOLF CLUB RD SE
Practice Address - Street 2:SUITE 204
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1048
Practice Address - Country:US
Practice Address - Phone:360-493-7469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006210363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8233256Medicaid
WA8233256Medicaid
WAAB05009Medicare ID - Type Unspecified