Provider Demographics
NPI:1689808347
Name:DAVIS, D'JARA LYSETTE (LPN)
Entity Type:Individual
Prefix:
First Name:D'JARA
Middle Name:LYSETTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 ELLIS WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-6520
Mailing Address - Country:US
Mailing Address - Phone:513-267-8556
Mailing Address - Fax:
Practice Address - Street 1:3607 ELLIS WAY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6520
Practice Address - Country:US
Practice Address - Phone:513-267-8556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.129816164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse