Provider Demographics
NPI:1154341196
Name:DAVIS, MONA M (NP)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:M
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:215 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1912
Mailing Address - Country:US
Mailing Address - Phone:208-799-3100
Mailing Address - Fax:208-799-0349
Practice Address - Street 1:215 10TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1912
Practice Address - Country:US
Practice Address - Phone:208-799-3100
Practice Address - Fax:208-799-0349
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP347A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9630088Medicaid
IDQ52812OtherDEA NUMBER
IDQ52812Medicare UPIN