Provider Demographics
NPI:1639293830
Name:DAVIS, MARYANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:920 OLIVER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5702
Practice Address - Country:US
Practice Address - Phone:318-807-6263
Practice Address - Fax:318-812-7348
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03438363LW0102X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1439916Medicaid
LA340215YJBUMedicare PIN