Provider Demographics
NPI:1265109409
Name:DAVIS, KELLY RANAE (APN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RANAE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W HIGGINS RD STE 1040
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-2049
Mailing Address - Country:US
Mailing Address - Phone:847-884-8096
Mailing Address - Fax:847-884-8125
Practice Address - Street 1:2500 W HIGGINS RD STE 1040
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-2049
Practice Address - Country:US
Practice Address - Phone:847-884-8096
Practice Address - Fax:847-884-8125
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023957363LF0000X
IAA165295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily