Provider Demographics
NPI:1265798979
Name:DAVIS, NICOLE ELIZABETH (DO)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1000 BRECKENRIDGE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-0839
Practice Address - Country:US
Practice Address - Phone:270-688-4480
Practice Address - Fax:270-688-4489
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY03827208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100361980Medicaid
KYK177630Medicare PIN