Basic Information
Provider Information | |||||||||
NPI: | 1013237163 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4616 W HOWARD LN | ||||||||
Address2: | L | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787286300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123248960 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 605 NE 9TH ST | ||||||||
Address2: |   | ||||||||
City: | SMITHVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 789571025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123605272 | ||||||||
FaxNumber: | 5123603060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2010 | ||||||||
LastUpdateDate: | 10/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 724111 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP119076 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 308799101 | 05 | TX |   | MEDICAID |