Provider Demographics
NPI:1972637262
Name:DAVIS, MARY ELLEN (LPN)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:22 HARFORD DR
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2909
Mailing Address - Country:US
Mailing Address - Phone:631-732-1021
Mailing Address - Fax:631-736-5016
Practice Address - Street 1:22 HARFORD DR
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-2909
Practice Address - Country:US
Practice Address - Phone:631-732-1021
Practice Address - Fax:631-736-5016
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108497-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02731708Medicaid