Provider Demographics
NPI:1548574312
Name:DAVIS, JILLIAN KEENE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:KEENE
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 1:25 W 68TH ST
Mailing Address - Street 2:APT 3H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 W 68TH ST
Practice Address - Street 2:APT 3H
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5302
Practice Address - Country:US
Practice Address - Phone:516-663-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5629741163W00000X
NY562974367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Yes163W00000XNursing Service ProvidersRegistered Nurse