Provider Demographics
NPI:1265608251
Name:DAVIS, RENEE L (DNP, APRN, CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DNP, APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 FRANK SCOTT PARKWAY WEST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5014
Mailing Address - Country:US
Mailing Address - Phone:618-257-2550
Mailing Address - Fax:618-257-2569
Practice Address - Street 1:3030 FRANK SCOTT PARKWAY WEST
Practice Address - Street 2:SUITE 1
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5014
Practice Address - Country:US
Practice Address - Phone:618-257-2550
Practice Address - Fax:618-257-2569
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090116363LP0200X
IL209-005885363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-005885Medicaid
IL036090116Medicaid