Provider Demographics
NPI:1518248699
Name:DAVIS, SHELLY ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ELIZABETH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 ASHLEY CIR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3362
Mailing Address - Country:US
Mailing Address - Phone:270-793-2165
Mailing Address - Fax:
Practice Address - Street 1:1801 ASHLEY CIR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3362
Practice Address - Country:US
Practice Address - Phone:270-793-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007042363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100185690Medicaid
KYK026776Medicare PIN