Basic Information
Provider Information | |||||||||
NPI: | 1215097746 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | ESTHER | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ADVANCED PRACTICE MI | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | ESTHER | ||||||||
OtherMiddleName: | LOUISE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ADVANCED PRACTICE MI | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4205 BELFORT RD STE 4015 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322163623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9044506014 | ||||||||
FaxNumber: | 9044506401 | ||||||||
Practice Location | |||||||||
Address1: | 5153 N 9TH AVE STE 307 | ||||||||
Address2: |   | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325045719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504166378 | ||||||||
FaxNumber: | 8504162278 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2006 | ||||||||
LastUpdateDate: | 07/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 1051239 | AL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   | 367A00000X | APRN11006773 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 569900125 | 05 | AL |   | MEDICAID |