Healthcare Provider Details

I. General information

NPI: 1396072153
Provider Name (Legal Business Name): VISHALLA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2009
Last Update Date: 11/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2533 W AUER AVE
MILWAUKEE WI
53206-1223
US

IV. Provider business mailing address

2533 W AUER AVE
MILWAUKEE WI
53206-1223
US

V. Phone/Fax

Practice location:
  • Phone: 414-243-9434
  • Fax:
Mailing address:
  • Phone: 414-243-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberD120-8777-7955-01
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberD120-8777-7955-01
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: