Basic Information
| Provider Information | |||||||||
| NPI: | 1649809922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42449 LAKELAND CT | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344201514 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6309 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133313435 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2020 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704230620 | MI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.