Provider Demographics
NPI:1588209373
Name:DAVIS, MARIAH K
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:K
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 1:94-1150 AWAIKI PL
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3260
Mailing Address - Country:US
Mailing Address - Phone:808-778-8062
Mailing Address - Fax:
Practice Address - Street 1:94-1150 AWAIKI PL
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3260
Practice Address - Country:US
Practice Address - Phone:808-778-8062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer