Healthcare Provider Details

I. General information

NPI: 1295967610
Provider Name (Legal Business Name): MISS DEBRA ANN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S WESTERN AVE
CHICAGO IL
60612-3531
US

IV. Provider business mailing address

610 S WESTERN AVE
CHICAGO IL
60612-3531
US

V. Phone/Fax

Practice location:
  • Phone: 312-226-9777
  • Fax: 312-226-9767
Mailing address:
  • Phone: 312-226-7145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: