Healthcare Provider Details

I. General information

NPI: 1881352151
Provider Name (Legal Business Name): LAURA LYNN LEE DAVIS RN,PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA LYNN LEE-DAVIS MSN,RN,PHN,PMH-BC

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 9TH ST STE A
MODESTO CA
95350-5814
US

IV. Provider business mailing address

500 N 9TH ST STE A
MODESTO CA
95350-5814
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-5300
  • Fax: 209-558-4586
Mailing address:
  • Phone: 209-525-5300
  • Fax: 209-558-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95090801
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number552199
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95090801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: