Provider Demographics
NPI:1538754866
Name:DAVIS, DESIREE N (PTA)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:N
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:NICOLE
Other - Last Name:SALAZAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1335 SW INDIAN GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0412
Mailing Address - Country:US
Mailing Address - Phone:386-590-7749
Mailing Address - Fax:
Practice Address - Street 1:6700 NW 10TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4213
Practice Address - Country:US
Practice Address - Phone:352-331-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29863225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant