Provider Demographics
NPI:1760029292
Name:DAVIS, GRACE LEE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:LEE
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 1:20907 SOUTHHOOK CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77073-5624
Mailing Address - Country:US
Mailing Address - Phone:832-301-3920
Mailing Address - Fax:
Practice Address - Street 1:20907 SOUTHHOOK CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77073-5624
Practice Address - Country:US
Practice Address - Phone:832-301-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21853504Medicaid