Healthcare Provider Details

I. General information

NPI: 1851956791
Provider Name (Legal Business Name): MRS. VETHILLA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VETHILLA HAIRSTON MSN, PMHNP

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

20 HERRELL RD
VILLA RICA GA
30180-5527
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-4781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN254248
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN254248
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: