Healthcare Provider Details

I. General information

NPI: 1730900036
Provider Name (Legal Business Name): KRISTIN ELIZABETH DAVIS RN, PHN, ACN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4023 MAIN ST
FAIR OAKS CA
95628-7520
US

IV. Provider business mailing address

4023 MAIN ST
FAIR OAKS CA
95628-7520
US

V. Phone/Fax

Practice location:
  • Phone: 831-818-3460
  • Fax:
Mailing address:
  • Phone: 831-818-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number845145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: