Provider Demographics
NPI:1750785051
Name:DAVIS, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:DAVIS
Suffix:
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 1:29 NAEK RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3942
Mailing Address - Country:US
Mailing Address - Phone:860-872-2289
Mailing Address - Fax:860-896-1425
Practice Address - Street 1:192 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5210
Practice Address - Country:US
Practice Address - Phone:860-649-3243
Practice Address - Fax:860-649-5092
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061496224OtherTAX ID