MEDICARE: GWENDOLYN 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	363LF0000X	Family Nurse Practitioner	A004882	AR

General Provider Information

NPI Number	:	1700320173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN DAVIS

Provider Business Mailing Address
First Line	:	626 POPLAR ST
Second Line	:
City	:	HELENA
State	:	AR
Zip	:	72342-3140
Country	:	US
Telephone Number	:	870-338-8163
Fax Number	:	870-338-7810

Provider Business Practice Location Address
First Line	:	626 POPLAR ST
Second Line	:
City	:	HELENA
State	:	AR
Zip	:	72342-3140
Country	:	US
Telephone Number	:	870-338-8163
Fax Number	:	870-338-7810

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

Provider Enumeration Date	:	12/05/2016
Last Update Date	:	12/05/2016

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Directions to “ GWENDOLYN DAVIS ” Practice Location

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