Provider Demographics
NPI:1770210791
Name:DAVIS, KELLY ANN
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
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 1:456 HORNER RUN
Mailing Address - Street 2:
Mailing Address - City:PENNSBORO
Mailing Address - State:WV
Mailing Address - Zip Code:26415-6051
Mailing Address - Country:US
Mailing Address - Phone:304-580-8934
Mailing Address - Fax:
Practice Address - Street 1:28407 STATE ROUTS 7
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750
Practice Address - Country:US
Practice Address - Phone:740-371-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHL.P.N.181758164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse