Provider Demographics
NPI:1124289798
Name:DAVIS, LISA ELLEN (CNM)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ELLEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ELLEN
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 413036
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3036
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0100
Practice Address - Country:US
Practice Address - Phone:801-581-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5522893-4402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000077933Medicare PIN