Healthcare Provider Details

I. General information

NPI: 1376769638
Provider Name (Legal Business Name): DEBRA MOLLIE DAVIS RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBRA MOLLIE WALTERS RN BSN

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2079 EDGEWATER DR
PEKIN IL
61554
US

IV. Provider business mailing address

587 E COURT ST
FARMINGTON IL
61531-1303
US

V. Phone/Fax

Practice location:
  • Phone: 309-382-2006
  • Fax: 309-382-2007
Mailing address:
  • Phone: 309-245-2862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: