Provider Demographics
NPI:1548638125
Name:DAVIS, MARYKAE (RN)
Entity type:Individual
Prefix:
First Name:MARYKAE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2849
Mailing Address - Country:US
Mailing Address - Phone:607-398-8608
Mailing Address - Fax:
Practice Address - Street 1:178 DENVER AVE
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-3030
Practice Address - Country:US
Practice Address - Phone:607-398-8608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-12
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY815465163WP0808X
NY323297164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty