MEDICARE: DIANE M DAVIS RN

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	163WC0400X	Case Management Registered Nurse	080045760RN	OR

General Provider Information

NPI Number	:	1528370186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE M DAVIS RN

Provider Business Mailing Address
First Line	:	11819 SE WILLIAM OTTY RD
Second Line	:
City	:	HAPPY VALLEY
State	:	OR
Zip	:	97086-8290
Country	:	US
Telephone Number	:	503-698-5334
Fax Number	:	503-698-5316

Provider Business Practice Location Address
First Line	:	11819 SE WILLIAM OTTY RD
Second Line	:
City	:	HAPPY VALLEY
State	:	OR
Zip	:	97086-8290
Country	:	US
Telephone Number	:	503-698-5334
Fax Number	:	503-698-5316

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

Provider Enumeration Date	:	07/11/2010
Last Update Date	:	07/11/2010

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