Healthcare Provider Details

I. General information

NPI: 1770431058
Provider Name (Legal Business Name): KISHA R DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

864 HARBOR WOODS DR
FAIRVIEW HEIGHTS IL
62208-2189
US

IV. Provider business mailing address

864 HARBOR WOODS DR
FAIRVIEW HEIGHTS IL
62208-2189
US

V. Phone/Fax

Practice location:
  • Phone: 314-448-5033
  • Fax:
Mailing address:
  • Phone: 314-448-5033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2026014984
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: