=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376922245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAKEISHA DAVIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2601 PECOS ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76119-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-531-7333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 321 CHRISTIE AVE
-----------------------------------------------------
City | EVERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76140-4520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-986-8732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------