Healthcare Provider Details

I. General information

NPI: 1558609321
Provider Name (Legal Business Name): KENNETH SAMUEL DAVIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

13250 SLAYDEN CIR
ASHLAND VA
23005-7460
US

V. Phone/Fax

Practice location:
  • Phone: 804-483-0000
  • Fax:
Mailing address:
  • Phone: 540-320-2967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024170579
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: