Provider Demographics
NPI:1659558799
Name:DAVIS, SHANICA (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:SHANICA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 AERO JET AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2803
Mailing Address - Country:US
Mailing Address - Phone:626-569-6149
Mailing Address - Fax:
Practice Address - Street 1:3400 AERO JET AVE FL 3
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2803
Practice Address - Country:US
Practice Address - Phone:626-569-6149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA545379163WC0400X
CA14639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily