Provider Demographics
NPI:1578676276
Name:DAVIS, JOAN ILENE (PT)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:ILENE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6128 N 12TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-1726
Mailing Address - Country:US
Mailing Address - Phone:602-212-1290
Mailing Address - Fax:
Practice Address - Street 1:4502 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1817
Practice Address - Country:US
Practice Address - Phone:602-499-8357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ389174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ781270OtherAHCCCS NUMBER