Provider Demographics
NPI:1144973777
Name:DAVIS, BAYLEE ASHTYNN
Entity type:Individual
Prefix:
First Name:BAYLEE
Middle Name:ASHTYNN
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 1:2215 BRIAN ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-4103
Mailing Address - Country:US
Mailing Address - Phone:618-704-5026
Mailing Address - Fax:
Practice Address - Street 1:1500 W SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-2535
Practice Address - Country:US
Practice Address - Phone:618-283-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005141224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant