Healthcare Provider Details

I. General information

NPI: 1235482449
Provider Name (Legal Business Name): MS. TRISTA SUZANNE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRISTA SUZANNE SELF

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 02/12/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE
AURORA CO
80045-7106
US

IV. Provider business mailing address

13123 E 16TH AVE
AURORA CO
80045-7106
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-6857
  • Fax:
Mailing address:
  • Phone: 865-803-7399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1642548
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN0000164063
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number2206
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAPN.0992491-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: