Provider Demographics
NPI:1134171572
Name:DAVIS, VICKY LYNN (FNP)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LYNN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:655 S CANFIELD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-7440
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:3960 E CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-6284
Practice Address - Country:US
Practice Address - Phone:636-225-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0000943-CNP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303644800Medicaid
FLY9940AMedicare ID - Type Unspecified