Provider Demographics
NPI:1316086788
Name:DAVIS, W CHRISTINE (NP)
Entity type:Individual
Prefix:
First Name:W CHRISTINE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3008
Mailing Address - Street 2:1250 CEDAR COURT
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903
Mailing Address - Country:US
Mailing Address - Phone:618-457-0450
Mailing Address - Fax:618-457-7329
Practice Address - Street 1:217 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:GOLCONDA
Practice Address - State:IL
Practice Address - Zip Code:62938
Practice Address - Country:US
Practice Address - Phone:618-683-3781
Practice Address - Fax:618-683-5802
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004159363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209004159Medicaid