Healthcare Provider Details

I. General information

NPI: 1871813550
Provider Name (Legal Business Name): JACQUELINE DAVIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE LANHAM APRN

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 E 10TH ST
JEFFERSONVILLE IN
47130-6016
US

IV. Provider business mailing address

200 CLINIC DRIVEV
MADISONVILLE KY
42431-1661
US

V. Phone/Fax

Practice location:
  • Phone: 812-288-2488
  • Fax: 812-288-6603
Mailing address:
  • Phone: 270-824-3682
  • Fax: 270-824-3675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71003616A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number49086
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006612
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3006612
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: