Provider Demographics
NPI:1609246966
Name:DAVIS, LISA RENEE (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:1107 BELLEFONTE RD
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-2503
Practice Address - Country:US
Practice Address - Phone:606-834-0125
Practice Address - Fax:606-834-0128
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0160366Medicaid
WV3810030198Medicaid
KY7100394660Medicaid
KY7100394660Medicaid