MEDICARE: BREONNA LASHAE DAVIS

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	103TS0200X	School Psychologist	0813000927	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023513108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREONNA LASHAE DAVIS

Provider Business Mailing Address
First Line	:	800 E CITY HALL AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23510-2723
Country	:	US
Telephone Number	:	270-366-5765
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 E CITY HALL AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23510-2723
Country	:	US
Telephone Number	:	270-366-5765
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	03/29/2018

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