Provider Demographics
NPI:1881352151
Name:LEE DAVIS, LAURA LYNN (RN,PHN)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LYNN
Last Name:LEE DAVIS
Suffix:
Gender:F
Credentials:RN,PHN
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:LYNN
Other - Last Name:LEE-DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN,PHN,PMH-BC
Mailing Address - Street 1:1001 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0730
Mailing Address - Country:US
Mailing Address - Phone:209-569-0373
Mailing Address - Fax:209-529-8519
Practice Address - Street 1:1001 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0730
Practice Address - Country:US
Practice Address - Phone:209-569-0373
Practice Address - Fax:209-529-8519
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95090801163WP0808X, 163W00000X
CA552199163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse