Provider Demographics
NPI:1104101344
Name:DAVIS, CAROL A (FNP-BC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 POWDERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4800
Mailing Address - Country:US
Mailing Address - Phone:307-634-1311
Mailing Address - Fax:307-634-1271
Practice Address - Street 1:6900 ALDEN DR. BLDG 160
Practice Address - Street 2:F.E. WARREN AFB
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82005-4800
Practice Address - Country:US
Practice Address - Phone:307-773-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY17455.1096163WC1500X, 163W00000X, 363LF0000X
WY17455363L00000X, 363LF0000X
CONP-990256363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1104101344Medicaid
WYW24642Medicare PIN