Provider Demographics
NPI:1174119309
Name:DAVIS, BRONWYN S (FNP)
Entity type:Individual
Prefix:
First Name:BRONWYN
Middle Name:S
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BRONWYN
Other - Middle Name:S
Other - Last Name:FREDERICKSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4260 NORTHRISE DR APT 1713
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7316
Mailing Address - Country:US
Mailing Address - Phone:575-571-9915
Mailing Address - Fax:
Practice Address - Street 1:4311 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8255
Practice Address - Country:US
Practice Address - Phone:575-522-4767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMF01210463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily