Provider Demographics
NPI:1578875050
Name:DAVIS, GLORIA JEAN (LICENSE PRACTICAL NU)
Entity Type:Individual
Prefix:MISS
First Name:GLORIA
Middle Name:JEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LICENSE PRACTICAL NU
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4368 N. 52ND STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216
Mailing Address - Country:US
Mailing Address - Phone:414-712-6760
Mailing Address - Fax:
Practice Address - Street 1:4368 N. 52ND STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216
Practice Address - Country:US
Practice Address - Phone:414-712-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24083-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse