Provider Demographics
NPI:1447845417
Name:DAVIS, REGINA (ANMT)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ANMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4618 W MARKET ST UNIT 106
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-2670
Mailing Address - Country:US
Mailing Address - Phone:925-587-9311
Mailing Address - Fax:
Practice Address - Street 1:4618 W MARKET ST UNIT 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-2670
Practice Address - Country:US
Practice Address - Phone:925-587-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252117225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist