Healthcare Provider Details

I. General information

NPI: 1154677334
Provider Name (Legal Business Name): JOHANNA DAVIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 SOUTH MAIN ST
MADISON ME
04950
US

IV. Provider business mailing address

42 DALLAS HILL RD
RANGELEY ME
04970-0569
US

V. Phone/Fax

Practice location:
  • Phone: 207-696-3992
  • Fax: 207-696-3974
Mailing address:
  • Phone: 207-864-2699
  • Fax: 207-864-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR058417
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: