Healthcare Provider Details

I. General information

NPI: 1972132421
Provider Name (Legal Business Name): MARYAM JALILA DAVIS CERTIFIED NURSING AS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 N 99TH AVE APT 3091
GLENDALE AZ
85305-3034
US

IV. Provider business mailing address

5150 N 99TH AVE APT 3091
GLENDALE AZ
85305-3034
US

V. Phone/Fax

Practice location:
  • Phone: 602-516-5096
  • Fax:
Mailing address:
  • Phone: 602-516-5096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number1000048010
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: