Provider Demographics
NPI:1457760803
Name:DAVIS-PRANKE, MARY WINIFRED (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WINIFRED
Last Name:DAVIS-PRANKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-350-4645
Practice Address - Street 1:1400 37TH ST
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-1906
Practice Address - Country:US
Practice Address - Phone:970-348-1112
Practice Address - Fax:970-348-1134
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8244555-4405208000000X
CO010221363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208000000XAllopathic & Osteopathic PhysiciansPediatrics