Provider Demographics
NPI:1508431156
Name:DAVIS, RANDISHA RENEA
Entity Type:Individual
Prefix:
First Name:RANDISHA
Middle Name:RENEA
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 1:604 SUBURBAN CT APT 5
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3837
Mailing Address - Country:US
Mailing Address - Phone:585-721-3042
Mailing Address - Fax:
Practice Address - Street 1:604 SUBURBAN CT APT 5
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3837
Practice Address - Country:US
Practice Address - Phone:585-721-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327866164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse