Provider Demographics
NPI:1295447563
Name:DAVIS, KIERSTYN JADE
Entity type:Individual
Prefix:
First Name:KIERSTYN
Middle Name:JADE
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 1:5855 FISHER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KENNA
Mailing Address - State:WV
Mailing Address - Zip Code:25248-7197
Mailing Address - Country:US
Mailing Address - Phone:304-514-8339
Mailing Address - Fax:
Practice Address - Street 1:5855 FISHER RIDGE RD
Practice Address - Street 2:
Practice Address - City:KENNA
Practice Address - State:WV
Practice Address - Zip Code:25248-7197
Practice Address - Country:US
Practice Address - Phone:304-514-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant