Provider Demographics
NPI:1215477054
Name:DAVIS, CASSANDRA J (APRN)
Entity type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:CASSANDRA
Other - Middle Name:J
Other - Last Name:KOEHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:SUBLETTE
Mailing Address - State:KS
Mailing Address - Zip Code:67877-0357
Mailing Address - Country:US
Mailing Address - Phone:620-510-5004
Mailing Address - Fax:
Practice Address - Street 1:100 W CHOUTEAU AVE
Practice Address - Street 2:
Practice Address - City:SUBLETTE
Practice Address - State:KS
Practice Address - Zip Code:67877-6738
Practice Address - Country:US
Practice Address - Phone:620-510-5004
Practice Address - Fax:620-510-5007
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77576363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKANSASMedicaid
KSPENDINGMedicare PIN