Provider Demographics
NPI:1972132421
Name:DAVIS, MARYAM JALILA (CERTIFIED NURSING AS)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:JALILA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CERTIFIED NURSING AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 N 99TH AVE APT 3091
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3034
Mailing Address - Country:US
Mailing Address - Phone:602-516-5096
Mailing Address - Fax:
Practice Address - Street 1:5150 N 99TH AVE APT 3091
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3034
Practice Address - Country:US
Practice Address - Phone:602-516-5096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RP1900X, 385H00000X, 385HR2055X, 385HR2060X, 385HR2065X
AZ1000048010376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child