Provider Demographics
NPI:1548497316
Name:DAVIS, AMY (RDMS 81478)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RDMS 81478
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33275 PACIFIC WAY
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-9226
Mailing Address - Country:US
Mailing Address - Phone:707-937-1477
Mailing Address - Fax:707-937-1480
Practice Address - Street 1:45040 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460
Practice Address - Country:US
Practice Address - Phone:707-937-1477
Practice Address - Fax:707-937-1480
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDMS814782471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDMS81478OtherRDMS