Basic Information
Provider Information | |||||||||
NPI: | 1760449375 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2151 OLD ROCKY RIDGE ROAD | ||||||||
Address2: | SUITE 106 | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352167251 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059891080 | ||||||||
FaxNumber: | 2059891087 | ||||||||
Practice Location | |||||||||
Address1: | 470 TAYLOR RD | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361173563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342264048 | ||||||||
FaxNumber: | 3343235675 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2006 | ||||||||
LastUpdateDate: | 09/23/2019 | ||||||||
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 | 367500000X | 1-056656 | AL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 000073769 | 05 | AL |   | MEDICAID | 430054184 | 01 | AL | MEDICARE RR | OTHER | 009937816 | 05 | AL |   | MEDICAID | 510-90432 | 01 | AL | BCBS | OTHER |