Provider Demographics
NPI:1063544930
Name:DAVIS, KATRINA ELLEN (CPNP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ELLEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 LORIAN LN SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3225
Mailing Address - Country:US
Mailing Address - Phone:503-585-4459
Mailing Address - Fax:
Practice Address - Street 1:891 23RD ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-364-2181
Practice Address - Fax:503-364-0364
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000028939N2PNPPP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269713Medicaid
OR269713Medicaid