Provider Demographics
NPI:1790006278
Name:DAVIS, KACIE AMANDA
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:AMANDA
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 1:1123 NE GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-5245
Mailing Address - Country:US
Mailing Address - Phone:405-605-7090
Mailing Address - Fax:
Practice Address - Street 1:1123 NE GRAND BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-5245
Practice Address - Country:US
Practice Address - Phone:056-057-0904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator