Provider Demographics
NPI:1801516695
Name:DAVIS, KENYATTA NECOLE
Entity type:Individual
Prefix:
First Name:KENYATTA
Middle Name:NECOLE
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 1:1995 BLUE ROCK CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-1834
Mailing Address - Country:US
Mailing Address - Phone:336-340-6399
Mailing Address - Fax:
Practice Address - Street 1:1995 BLUE ROCK CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-1834
Practice Address - Country:US
Practice Address - Phone:336-340-6399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-1232320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities