Healthcare Provider Details

I. General information

NPI: 1649809922
Provider Name (Legal Business Name): LAURA A DAVIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6309 MACK AVE
DETROIT MI
48207-2302
US

IV. Provider business mailing address

42449 LAKELAND CT
PLYMOUTH MI
48170-2518
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-3435
  • Fax:
Mailing address:
  • Phone: 734-420-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704230620
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: