Provider Demographics
NPI:1780432211
Name:DAVIS, KELLY ANN (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 TROUT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-8424
Mailing Address - Country:US
Mailing Address - Phone:719-201-7284
Mailing Address - Fax:
Practice Address - Street 1:565 SPACE CENTER DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-3609
Practice Address - Country:US
Practice Address - Phone:719-201-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0172013163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care