Provider Demographics
NPI:1891475455
Name:DAVIS, MINA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W RINCON ST UNIT 412
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-5710
Mailing Address - Country:US
Mailing Address - Phone:951-532-9913
Mailing Address - Fax:
Practice Address - Street 1:321 W RINCON ST UNIT 412
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92878-5710
Practice Address - Country:US
Practice Address - Phone:951-532-9913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025097363LF0000X
CA95191633163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily