Provider Demographics
NPI:1245924760
Name:DAVIS, LETISHA
Entity type:Individual
Prefix:
First Name:LETISHA
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 1:12208 PINEHURST LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2633
Mailing Address - Country:US
Mailing Address - Phone:810-877-4992
Mailing Address - Fax:
Practice Address - Street 1:12208 PINEHURST LN
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2633
Practice Address - Country:US
Practice Address - Phone:810-877-4992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703128281164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse