=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033392170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTY K DAVIS DO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2007
-----------------------------------------------------
Last Update Date | 03/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 916 MYRTLE ST
-----------------------------------------------------
City | STURGIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49091-2326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-251-1064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27100 MAHLE LANDING RD
-----------------------------------------------------
City | STURGIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49091-9150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-251-1064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SELF
-----------------------------------------------------
Name | KRISTY K DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-251-1064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------