Basic Information
Provider Information | |||||||||
NPI: | 1093844136 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | MARYANN | ||||||||
MiddleName: | HICKEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17240 JUNCTION RD | ||||||||
Address2: |   | ||||||||
City: | ADDISON | ||||||||
State: | MI | ||||||||
PostalCode: | 492208704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5175477568 | ||||||||
FaxNumber: | 5175475196 | ||||||||
Practice Location | |||||||||
Address1: | 4650 W US HIGHWAY 223 | ||||||||
Address2: |   | ||||||||
City: | ADRIAN | ||||||||
State: | MI | ||||||||
PostalCode: | 492218494 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5172662588 | ||||||||
FaxNumber: | 5172660224 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704121801 | MI | Y |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 21114612 | OH | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.