Provider Demographics
NPI:1568075604
Name:DAVIS, MICHELLE L (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S 1100 E STE 305
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4500
Mailing Address - Country:US
Mailing Address - Phone:385-290-1289
Mailing Address - Fax:
Practice Address - Street 1:24 S 1100 E STE 305
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4500
Practice Address - Country:US
Practice Address - Phone:385-290-1289
Practice Address - Fax:385-290-1290
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7760277-4409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily