Basic Information
| Provider Information | |||||||||
| NPI: | 1043853302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSN, APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 SIMPSON CREEK RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400086110 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 W JOHN ROWAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400042663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023377409 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2019 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3013878 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.