Provider Demographics
NPI:1295278331
Name:DAVIS, KIMBERLY CRISP I
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CRISP
Last Name:DAVIS
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 JCA RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NY
Mailing Address - Zip Code:13076-3152
Mailing Address - Country:US
Mailing Address - Phone:315-720-2364
Mailing Address - Fax:
Practice Address - Street 1:171 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2548
Practice Address - Country:US
Practice Address - Phone:315-724-4286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist