Healthcare Provider Details

I. General information

NPI: 1326460205
Provider Name (Legal Business Name): AMANDA RAE DAVIS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MARKET ST
BOARDMAN OH
44512
US

IV. Provider business mailing address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-4298
  • Fax: 330-729-1897
Mailing address:
  • Phone: 330-729-4298
  • Fax: 330-729-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA-15217
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: