Provider Demographics
NPI:1154993749
Name:DAVIS, TRELLA
Entity type:Individual
Prefix:
First Name:TRELLA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 IROQUOIS
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-8277
Mailing Address - Country:US
Mailing Address - Phone:620-214-3693
Mailing Address - Fax:
Practice Address - Street 1:260 IROQUOIS
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:CO
Practice Address - Zip Code:80540-8277
Practice Address - Country:US
Practice Address - Phone:620-214-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer