Provider Demographics
NPI:1922516723
Name:DAVIS, KEITHA (APRN, FNP-BC, FPA)
Entity Type:Individual
Prefix:
First Name:KEITHA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN, FNP-BC, FPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 S WOOD ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3747
Mailing Address - Country:US
Mailing Address - Phone:312-996-2779
Mailing Address - Fax:312-355-2983
Practice Address - Street 1:1009 S WOOD ST FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3747
Practice Address - Country:US
Practice Address - Phone:312-996-2779
Practice Address - Fax:312-355-2983
Is Sole Proprietor?:No
Enumeration Date:2018-01-14
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017061363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner