Provider Demographics
NPI:1396089546
Name:DAVIS, TASHA M (LPN)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6885 SCOTCH LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3984
Mailing Address - Country:US
Mailing Address - Phone:248-825-5537
Mailing Address - Fax:
Practice Address - Street 1:6885 SCOTCH LAKE DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-3984
Practice Address - Country:US
Practice Address - Phone:248-825-5537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-11
Last Update Date:2012-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703103622164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse