Healthcare Provider Details

I. General information

NPI: 1346955895
Provider Name (Legal Business Name): COMPLEXION MEDICAL SPA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W FORT MACON RD
ATLANTIC BEACH NC
28512-5303
US

IV. Provider business mailing address

201 W FORT MACON RD
ATLANTIC BEACH NC
28512-5303
US

V. Phone/Fax

Practice location:
  • Phone: 252-773-0841
  • Fax: 252-773-0737
Mailing address:
  • Phone: 252-773-0841
  • Fax: 252-773-0737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. CASSANDRA DAVIS
Title or Position: DNP, FNP-BC
Credential: FNP-BC
Phone: 252-725-3844