Provider Demographics
NPI:1053134023
Name:DAVIS, KATIE NICOLE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:NICOLE
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 1:404 E WATOVA ST
Mailing Address - Street 2:
Mailing Address - City:TALALA
Mailing Address - State:OK
Mailing Address - Zip Code:74080-9542
Mailing Address - Country:US
Mailing Address - Phone:719-280-7853
Mailing Address - Fax:
Practice Address - Street 1:404 E WATOVA ST
Practice Address - Street 2:
Practice Address - City:TALALA
Practice Address - State:OK
Practice Address - Zip Code:74080-9542
Practice Address - Country:US
Practice Address - Phone:719-280-7853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist