Healthcare Provider Details

I. General information

NPI: 1104173632
Provider Name (Legal Business Name): JENNY DAVIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 GRAND ST
NEW YORK NY
10002-4629
US

IV. Provider business mailing address

60 MADISON AVE FL 5
NEW YORK NY
10010-1600
US

V. Phone/Fax

Practice location:
  • Phone: 212-634-7550
  • Fax: 646-935-4665
Mailing address:
  • Phone: 212-545-2438
  • Fax: 646-312-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP121060
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF342969
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: