Provider Demographics
NPI:1588815534
Name:DAVIS, MARY NEWBERRY (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NEWBERRY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:NEWBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:9 COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6118
Mailing Address - Country:US
Mailing Address - Phone:415-842-5000
Mailing Address - Fax:415-842-5163
Practice Address - Street 1:1260 S ELISEO DR
Practice Address - Street 2:FLOOR 2
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2009
Practice Address - Country:US
Practice Address - Phone:415-924-1214
Practice Address - Fax:415-924-1375
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1505367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW1505OtherMEDICAL LICENSE