Basic Information
| Provider Information | |||||||||
| NPI: | 1457911810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 5TH ST | ||||||||
| Address2: | |||||||||
| City: | WOOD RIVER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620951708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185600014 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4414 W CENTER DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185098454 | ||||||||
| FaxNumber: | 6185094870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2019 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209016701 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 209016701 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 900068033-62269-01 | 05 | IL | MEDICAID |