Provider Demographics
NPI:1811415342
Name:DAVIS, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
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:PO BOX 746721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6721
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:4417 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639
Practice Address - Country:US
Practice Address - Phone:773-377-7736
Practice Address - Fax:815-642-5723
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016460363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner