Provider Demographics
NPI:1538142864
Name:DAVIS, CONNIE M (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CPNP
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 927
Mailing Address - Street 2:
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-0927
Mailing Address - Country:US
Mailing Address - Phone:503-728-0424
Mailing Address - Fax:
Practice Address - Street 1:401 SW BEL AIR DRIVE
Practice Address - Street 2:
Practice Address - City:CLATSKANIE
Practice Address - State:OR
Practice Address - Zip Code:97016
Practice Address - Country:US
Practice Address - Phone:503-728-0424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR32996363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0201816OtherWASHINGTON L & I
OR277983Medicaid
ORL3054-02OtherPACIFIC SOURCE
ORL3054-02OtherPACIFIC SOURCE
OR277983Medicaid