Healthcare Provider Details

I. General information

NPI: 1053807420
Provider Name (Legal Business Name): JANETT DAVIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 VETERANS PKWY S
MOULTRIE GA
31788-6705
US

IV. Provider business mailing address

31 W CARRIE CT
BLAKELY GA
39823-2820
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-4815
  • Fax:
Mailing address:
  • Phone: 229-308-0824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN195675
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number195675
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: