MEDICARE: LAKEISHA DAVIS

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1376922245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEISHA DAVIS

Provider Business Mailing Address
First Line	:	321 CHRISTIE AVE
Second Line	:
City	:	EVERMAN
State	:	TX
Zip	:	76140-4520
Country	:	US
Telephone Number	:	817-986-8732
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 PECOS ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-5609
Country	:	US
Telephone Number	:	817-531-7333
Fax Number	:

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

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	05/26/2015

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Directions to “ LAKEISHA DAVIS ” Practice Location

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