Healthcare Provider Details

I. General information

NPI: 1063574630
Provider Name (Legal Business Name): ANGELA M. DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 S 12TH ST
CAMBRIDGE OH
43725-2417
US

IV. Provider business mailing address

216 S 12TH ST
CAMBRIDGE OH
43725-2417
US

V. Phone/Fax

Practice location:
  • Phone: 740-584-5821
  • Fax:
Mailing address:
  • Phone: 740-584-5821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number2487063
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: