Provider Demographics
NPI:1619392123
Name:DAVIS, CONNIE LAVON (GNP-BC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LAVON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:GNP-BC
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 2093
Mailing Address - Street 2:
Mailing Address - City:SUMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98295-2093
Mailing Address - Country:US
Mailing Address - Phone:604-991-4563
Mailing Address - Fax:
Practice Address - Street 1:3130 SQUALICUM PKWY STE 100
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1940
Practice Address - Country:US
Practice Address - Phone:360-756-0382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN0077001163W00000X
WAAP30003227363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse