Healthcare Provider Details

I. General information

NPI: 1851110654
Provider Name (Legal Business Name): KRISTY ANN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W POWELL BLVD
GRESHAM OR
97030-7051
US

IV. Provider business mailing address

2317 SE BEAVER CREEK LN
TROUTDALE OR
97060-2353
US

V. Phone/Fax

Practice location:
  • Phone: 503-453-2420
  • Fax:
Mailing address:
  • Phone: 503-453-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14064861
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: