Basic Information
| Provider Information | |||||||||
| NPI: | 1194032417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JENNISE | ||||||||
| MiddleName: | OLIVIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11936 201ST ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114123810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474550687 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9715 64TH RD | ||||||||
| Address2: | |||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113742250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184595592 | ||||||||
| FaxNumber: | 7184596047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 09/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 631834 | NY | Y | Nursing Service Providers | Registered Nurse |
No ID Information.