Healthcare Provider Details

I. General information

NPI: 1366048357
Provider Name (Legal Business Name): JENNIFER LYNN DAVIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13611 SCHANG RD
EAST AURORA NY
14052-9595
US

IV. Provider business mailing address

612 CORPORATE WAY STE 2M
VALLEY COTTAGE NY
10989-2027
US

V. Phone/Fax

Practice location:
  • Phone: 845-996-8176
  • Fax:
Mailing address:
  • Phone: 845-996-8176
  • Fax: 718-362-8185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF310104-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: