Provider Demographics
NPI:1295344562
Name:DAVIS, SHANTA KATICE (APRN)
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:KATICE
Last Name:DAVIS
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 17TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-2418
Mailing Address - Country:US
Mailing Address - Phone:727-741-8475
Mailing Address - Fax:
Practice Address - Street 1:6740 CROSSWINDS DR N STE C
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5472
Practice Address - Country:US
Practice Address - Phone:727-954-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008236363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty