MEDICARE: KINGDOM RESERVES PSYCHIATRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1013861913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDOM RESERVES PSYCHIATRY

Provider Business Mailing Address
First Line	:	901 ROYAL MILL AVE APT 335
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-1686
Country	:	US
Telephone Number	:	984-231-9750
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 ROYAL MILL AVE APT 335
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-1686
Country	:	US
Telephone Number	:	984-231-9750
Fax Number	:

Authorized Official
Title or Position	:	PMHNP
Name	:	TAMEKA DAVIS
Credential	:	PMHNP
Telephone Number	:	832-978-4855

Provider Enumeration Date	:	02/26/2026
Last Update Date	:	02/26/2026

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