Healthcare Provider Details

I. General information

NPI: 1013460104
Provider Name (Legal Business Name): BEVERLY A MARTIN-DAVIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PALMETTO PK BLVD
LEXINGTON SC
29072-7872
US

IV. Provider business mailing address

301 PALMETTO PK BLVD
LEXINGTON SC
29072-7872
US

V. Phone/Fax

Practice location:
  • Phone: 803-399-9204
  • Fax:
Mailing address:
  • Phone: 803-399-9204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001239655
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: