Provider Demographics
NPI:1881290005
Name:DAVIS, KEONA CHANTEL
Entity type:Individual
Prefix:
First Name:KEONA
Middle Name:CHANTEL
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 1:31 SIBLEY ST STE A31E
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46320-1725
Mailing Address - Country:US
Mailing Address - Phone:219-802-8800
Mailing Address - Fax:219-802-8801
Practice Address - Street 1:31 SIBLEY ST STE A31E
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1725
Practice Address - Country:US
Practice Address - Phone:219-802-8800
Practice Address - Fax:219-802-8801
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010690A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily