Provider Demographics
NPI:1588624381
Name:DAVIS, KIM GENELLE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:GENELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SW 10TH AVE
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604
Mailing Address - Country:US
Mailing Address - Phone:785-354-6241
Mailing Address - Fax:785-270-4343
Practice Address - Street 1:118 W. 4TH
Practice Address - Street 2:
Practice Address - City:LEBO
Practice Address - State:KS
Practice Address - Zip Code:66856
Practice Address - Country:US
Practice Address - Phone:620-256-6346
Practice Address - Fax:620-256-6219
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100428830DMedicaid
KS100428830EMedicaid
KS068002265OtherMEDICARE PTAN
KS161507OtherBCBS
P92213Medicare UPIN