Provider Demographics
NPI:1578228821
Name:DAVIS, DESIREE' JOLENE
Entity Type:Individual
Prefix:PROF
First Name:DESIREE'
Middle Name:JOLENE
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 1:1202 BLACK LAKE BLVD SW STE B
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-7208
Mailing Address - Country:US
Mailing Address - Phone:360-968-4326
Mailing Address - Fax:
Practice Address - Street 1:1202 BLACK LAKE BLVD SW STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-7208
Practice Address - Country:US
Practice Address - Phone:360-968-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist