Provider Demographics
NPI:1831463371
Name:DAVIS, ETTA PEARL
Entity Type:Individual
Prefix:
First Name:ETTA
Middle Name:PEARL
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 1:4638 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3429
Mailing Address - Country:US
Mailing Address - Phone:405-670-4644
Mailing Address - Fax:405-670-4444
Practice Address - Street 1:4638 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3429
Practice Address - Country:US
Practice Address - Phone:405-670-4644
Practice Address - Fax:405-670-4444
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator