=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881352151
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA LYNN LEE DAVIS RN,PHN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2021
-----------------------------------------------------
Last Update Date | 06/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 N 9TH ST STE A
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-5814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-525-5300
-----------------------------------------------------
Fax | 209-558-4586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 N 9TH ST STE A
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-5814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-525-5300
-----------------------------------------------------
Fax | 209-558-4586
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 95090801
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Registered Nurse
-----------------------------------------------------
License Number | 552199
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 95090801
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------