Provider Demographics
NPI:1992211700
Name:DAVIS, LAURIE A (APRN, NP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3510
Practice Address - Country:US
Practice Address - Phone:812-275-1381
Practice Address - Fax:811-275-1299
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008132A363L00000X, 363LF0000X
KY3011764363L00000X, 363LF0000X
TN35215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011416Medicaid
IN090540834OtherMEDICARE
KY7100498320Medicaid