Healthcare Provider Details

I. General information

NPI: 1720123334
Provider Name (Legal Business Name): JANICE O DAVIE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 S BALLPARK DR
FRANKLIN WI
53132-6908
US

IV. Provider business mailing address

3658 W CYPRESS LN
FRANKLIN WI
53132-8782
US

V. Phone/Fax

Practice location:
  • Phone: 414-224-9622
  • Fax:
Mailing address:
  • Phone: 414-364-3816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number167
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: