Provider Demographics
NPI:1629946223
Name:DAVIS, DEIDRA
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
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 1:1202 DUNVEGAN LN
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-7880
Mailing Address - Country:US
Mailing Address - Phone:469-408-8566
Mailing Address - Fax:
Practice Address - Street 1:1202 DUNVEGAN LN
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-7880
Practice Address - Country:US
Practice Address - Phone:469-408-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health