Basic Information
Provider Information | |||||||||
NPI: | 1780759605 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | NATALIE | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BLACK | ||||||||
OtherFirstName: | NATALIE | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 240 GRACE NELL DR | ||||||||
Address2: |   | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420035797 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2703310218 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 S 12TH ST | ||||||||
Address2: |   | ||||||||
City: | MURRAY | ||||||||
State: | KY | ||||||||
PostalCode: | 420719303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707599200 | ||||||||
FaxNumber: | 2707599966 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/24/2006 | ||||||||
LastUpdateDate: | 12/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/12/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 109023 | MO | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 208000000X | 43241 | KY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 000635268 | 01 | KY | BC | OTHER | 209227917 | 05 | MO |   | MEDICAID | 7100095020 | 05 | KY |   | MEDICAID |