Provider Demographics
NPI:1558132969
Name:DAVIS, MYKAELA
Entity Type:Individual
Prefix:
First Name:MYKAELA
Middle Name:
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 1:1565 S PLEASANTS HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:WV
Mailing Address - Zip Code:26170-9055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1565 S PLEASANTS HWY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:WV
Practice Address - Zip Code:26170-9055
Practice Address - Country:US
Practice Address - Phone:740-629-8026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant