MEDICARE: KEISHA DAVIS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	499498-1	NY

General Provider Information

NPI Number	:	1275804114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHA DAVIS RN

Provider Business Mailing Address
First Line	:	181 N LONG BEACH AVE
Second Line	:
City	:	FREEPORT
State	:	NY
Zip	:	11520-2102
Country	:	US
Telephone Number	:	212-470-4833
Fax Number	:

Provider Business Practice Location Address
First Line	:	181 N LONG BEACH AVE
Second Line	:
City	:	FREEPORT
State	:	NY
Zip	:	11520-2102
Country	:	US
Telephone Number	:	212-470-4833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2012
Last Update Date	:	01/24/2012

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