Provider Demographics
NPI:1124042908
Name:DAVIS, KIM STOKES (CRNA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:STOKES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 LAKE IDA WAY NW
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-9768
Mailing Address - Country:US
Mailing Address - Phone:320-834-2313
Mailing Address - Fax:651-646-3124
Practice Address - Street 1:1544 SHELDON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-2331
Practice Address - Country:US
Practice Address - Phone:651-646-3091
Practice Address - Fax:651-646-3124
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 074029-2163W00000X
MN026303367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered