Provider Demographics
NPI:1811708613
Name:DAVIS, SHAYLEIGH (PTA)
Entity type:Individual
Prefix:
First Name:SHAYLEIGH
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 S 5TH W APT 9203
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1043
Mailing Address - Country:US
Mailing Address - Phone:208-241-3546
Mailing Address - Fax:
Practice Address - Street 1:2570 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7515
Practice Address - Country:US
Practice Address - Phone:208-529-8005
Practice Address - Fax:208-529-0251
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4571342225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant