Provider Demographics
NPI:1629324108
Name:DAVIS, PHILLIP H (RN)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:H
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ROCKNE ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6043
Mailing Address - Country:US
Mailing Address - Phone:707-400-3021
Mailing Address - Fax:
Practice Address - Street 1:1477 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1906
Practice Address - Country:US
Practice Address - Phone:718-979-6900
Practice Address - Fax:718-979-6940
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY570671163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse