Healthcare Provider Details

I. General information

NPI: 1912734633
Provider Name (Legal Business Name): MS. ELIZABETH DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9405 BRYANT FARMS RD
CHARLOTTE NC
28277-1642
US

IV. Provider business mailing address

1429 BRYANT ST STE A
CHARLOTTE NC
28208-5201
US

V. Phone/Fax

Practice location:
  • Phone: 980-207-2707
  • Fax: 980-207-2783
Mailing address:
  • Phone: 704-919-0867
  • Fax: 704-817-8579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-6388
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: