MEDICARE: MISS GLORIA JEAN DAVIS LICENSE PRACTICAL NU

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	24083-31	WI

General Provider Information

NPI Number	:	1578875050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS GLORIA JEAN DAVIS LICENSE PRACTICAL NU

Provider Business Mailing Address
First Line	:	4368 N. 52ND STREET
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216
Country	:	US
Telephone Number	:	414-712-6760
Fax Number	:

Provider Business Practice Location Address
First Line	:	4368 N. 52ND STREET
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216
Country	:	US
Telephone Number	:	414-712-6760
Fax Number	:

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

Provider Enumeration Date	:	07/13/2010
Last Update Date	:	07/13/2010

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