Basic Information
| Provider Information | |||||||||
| NPI: | 1013456201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TAMIKA | ||||||||
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| Credential: | ADULT-GERONTOLOGY PR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W MONROE ST STE 1200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606032420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 32605 W 12 MILE RD STE 195 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133062023 | ||||||||
| FaxNumber: | 8884426976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2017 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 4704272126 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | 224736 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 527474 | 05 | AZ | MEDICAID |