MEDICARE: DEIDRE A.L 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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1861253205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRE A.L DAVIS

Provider Business Mailing Address
First Line	:	800 CHICAGO ST APT 2
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-3966
Country	:	US
Telephone Number	:	920-217-4266
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 CHICAGO ST APT 2
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-3966
Country	:	US
Telephone Number	:	920-217-4266
Fax Number	:

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

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	09/11/2025

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