Provider Demographics
NPI:1396072153
Name:DAVIS, VISHALLA
Entity type:Individual
Prefix:
First Name:VISHALLA
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 1:2533 W AUER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1223
Mailing Address - Country:US
Mailing Address - Phone:414-243-9434
Mailing Address - Fax:
Practice Address - Street 1:2533 W AUER AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1223
Practice Address - Country:US
Practice Address - Phone:414-243-9434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-14
Last Update Date:2009-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WID120-8777-7955-01171WH0202X, 172V00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171WH0202XOther Service ProvidersContractorHome Modifications