Provider Demographics
NPI:1083506471
Name:DAVIS, KENYATT RENEE
Entity type:Individual
Prefix:
First Name:KENYATT
Middle Name:RENEE
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 1:10757 HORTENSE ST APT 208
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-1842
Mailing Address - Country:US
Mailing Address - Phone:404-457-3031
Mailing Address - Fax:
Practice Address - Street 1:10757 HORTENSE ST APT 208
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-1842
Practice Address - Country:US
Practice Address - Phone:404-457-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95035164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty