MEDICARE: KELLY M DAVIS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	026.0021185	VT
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	101.0134392	VT

General Provider Information

NPI Number	:	1164980082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY M DAVIS APRN

Provider Business Mailing Address
First Line	:	132 FURNACE BROOK RD
Second Line	:
City	:	BENNINGTON
State	:	VT
Zip	:	05201-8258
Country	:	US
Telephone Number	:	802-733-4883
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 CHURCH ST
Second Line	:
City	:	ARLINGTON
State	:	VT
Zip	:	05250-4457
Country	:	US
Telephone Number	:	802-733-4883
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2019
Last Update Date	:	11/15/2019

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