Provider Demographics
NPI:1821567009
Name:DAVIS, VERSHAWN MACHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:VERSHAWN
Middle Name:MACHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6561 N HIX RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1958
Mailing Address - Country:US
Mailing Address - Phone:313-740-3777
Mailing Address - Fax:
Practice Address - Street 1:6561 N HIX RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1958
Practice Address - Country:US
Practice Address - Phone:313-740-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-17
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703098181164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid