Healthcare Provider Details

I. General information

NPI: 1164724787
Provider Name (Legal Business Name): AMANDA NICOLE DAVIS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 PATTONSVILLE RD
JACKSON OH
45640-9452
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 740-395-8805
  • Fax: 740-395-8855
Mailing address:
  • Phone: 740-992-0060
  • Fax: 740-446-5854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.12007-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: