Provider Demographics
NPI:1356588123
Name:DAVIS, QUEEN MARY (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:QUEEN
Middle Name:MARY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 S GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-5032
Mailing Address - Country:US
Mailing Address - Phone:323-933-9014
Mailing Address - Fax:323-937-1872
Practice Address - Street 1:1807 S GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-5032
Practice Address - Country:US
Practice Address - Phone:323-933-9014
Practice Address - Fax:323-937-1872
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA #0367076172A00000X
CACA# 0367076172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANAICS 624120OtherSERVICE FOR ELDERLY AND PERSONS WITH DISABILITIES
CACA# 0367076OtherDEPARTMENT OF MOTOR VEHICLES- MOTOR CARRIER
0055719OtherCALIFORNIA SMALL BUSINESS CERTIFICATION
0055719OtherREGISTERED LOS ANGELES COUNTY VENDOR
CASIC 8322OtherINDIVIDUAL & FAMILY SOCIAL SERVICE
CA20080702766OtherFICTITIOUS BUSINESS NAME STATEMENT