Provider Demographics
NPI:1699003210
Name:DAVIS, DAMON (AHCNS)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:AHCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 COUNTY ROAD 468
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2989
Mailing Address - Country:US
Mailing Address - Phone:573-778-2888
Mailing Address - Fax:
Practice Address - Street 1:3100 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8686
Practice Address - Country:US
Practice Address - Phone:573-727-9311
Practice Address - Fax:573-785-0182
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009033936364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health