Provider Demographics
NPI:1649741430
Name:DAVIS, MARY KATHY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHY
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 1:19836 ECR163
Mailing Address - Street 2:
Mailing Address - City:OLUSTEE
Mailing Address - State:OK
Mailing Address - Zip Code:73560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 N OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-3000
Practice Address - Country:US
Practice Address - Phone:580-782-5912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK736021103OtherMANGUM PUBLIC SCHOOLS