Provider Demographics
NPI:1861000820
Name:DAVIS, VANESSA R
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:R
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 1:2352 WINDY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-1474
Mailing Address - Country:US
Mailing Address - Phone:231-780-8283
Mailing Address - Fax:
Practice Address - Street 1:2352 WINDY RIDGE DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-1474
Practice Address - Country:US
Practice Address - Phone:231-780-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5801000183343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICV0056702Medicaid