Provider Demographics
NPI:1578938726
Name:DAVIS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:8656 LAGO VISTA PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1166
Mailing Address - Country:US
Mailing Address - Phone:541-680-1165
Mailing Address - Fax:
Practice Address - Street 1:8656 LAGO VISTA PL
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1166
Practice Address - Country:US
Practice Address - Phone:541-680-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-13
Last Update Date:2015-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist