Healthcare Provider Details

I. General information

NPI: 1609246966
Provider Name (Legal Business Name): LISA RENEE DAVIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 BELLEFONTE RD
FLATWOODS KY
41139-2503
US

IV. Provider business mailing address

PO BOX 1595
ASHLAND KY
41105-1595
US

V. Phone/Fax

Practice location:
  • Phone: 606-834-0125
  • Fax: 606-834-0128
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009600
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: