MEDICARE: SELENA DAVIS

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	164W00000X	Licensed Practical Nurse	165169	OH

General Provider Information

NPI Number	:	1568042364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELENA DAVIS

Provider Business Mailing Address
First Line	:	1354 W WOODRUFF AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43606-4772
Country	:	US
Telephone Number	:	419-290-8892
Fax Number	:

Provider Business Practice Location Address
First Line	:	1354 W WOODRUFF AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43606-4772
Country	:	US
Telephone Number	:	419-290-8892
Fax Number	:

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

Provider Enumeration Date	:	04/14/2021
Last Update Date	:	05/19/2021

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Directions to “ SELENA DAVIS ” Practice Location

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