MEDICARE: SUESAN 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	163W00000X	Registered Nurse	129418	CO

General Provider Information

NPI Number	:	1639404965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUESAN DAVIS RN

Provider Business Mailing Address
First Line	:	4981 DUNECREST DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-3564
Country	:	US
Telephone Number	:	817-602-2529
Fax Number	:

Provider Business Practice Location Address
First Line	:	4981 DUNECREST DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-3564
Country	:	US
Telephone Number	:	817-602-2529
Fax Number	:

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

Provider Enumeration Date	:	10/05/2009
Last Update Date	:	10/05/2009

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