Basic Information
| Provider Information | |||||||||
| NPI: | 1952434722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | ROSETTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24 | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723890024 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 515 MCDONOUGH | ||||||||
| Address2: | |||||||||
| City: | HELENA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723422912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703388106 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 373H00000X | Y | Nursing Service Related Providers | Day Training/Habilitation Specialist |
No ID Information.