Provider Demographics
NPI:1760629109
Name:DAVIS, HEATHER JO (CNP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:JO
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 DIXMYTH AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-2475
Mailing Address - Country:US
Mailing Address - Phone:513-862-2514
Mailing Address - Fax:513-862-4189
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-862-2514
Practice Address - Fax:513-862-4189
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA222688363LN0000X
OHCOA.10175-NP363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA222688OtherSTATE LICENSE
LA2574736Medicaid