Provider Demographics
NPI:1659917771
Name:DAVIS, LYNDI (NP)
Entity Type:Individual
Prefix:MRS
First Name:LYNDI
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 1:3534 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1361
Mailing Address - Country:US
Mailing Address - Phone:260-478-5110
Mailing Address - Fax:260-478-5133
Practice Address - Street 1:3534 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1361
Practice Address - Country:US
Practice Address - Phone:260-478-5110
Practice Address - Fax:260-478-5133
Is Sole Proprietor?:No
Enumeration Date:2019-11-24
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF08190482363LF0000X
IN71009631A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300034089Medicaid