Healthcare Provider Details

I. General information

NPI: 1891192985
Provider Name (Legal Business Name): AMANDA KATHLEEN DAVIS MSN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 ALLEN RD STE 420
STOW OH
44224-1070
US

IV. Provider business mailing address

63 BAKER BLVD
FAIRLAWN OH
44333-3601
US

V. Phone/Fax

Practice location:
  • Phone: 330-865-4644
  • Fax: 330-865-4641
Mailing address:
  • Phone: 330-572-0645
  • Fax: 330-572-0645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number16668-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: