Provider Demographics
NPI:1609507508
Name:DAVIS, CORRINE TESS
Entity Type:Individual
Prefix:
First Name:CORRINE
Middle Name:TESS
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 1:907 CAPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1657
Mailing Address - Country:US
Mailing Address - Phone:907-463-6878
Mailing Address - Fax:907-463-6879
Practice Address - Street 1:907 CAPITAL AVE
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1657
Practice Address - Country:US
Practice Address - Phone:907-463-6878
Practice Address - Fax:907-463-6879
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK191877363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health