Healthcare Provider Details

I. General information

NPI: 1932767928
Provider Name (Legal Business Name): DIANE KELLY DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 JESSIE DUPONT MEMORIAL HWY
BURGESS VA
22432-2038
US

IV. Provider business mailing address

1126 SANDY POINT RD
HEATHSVILLE VA
22473-4494
US

V. Phone/Fax

Practice location:
  • Phone: 804-220-2010
  • Fax: 804-299-4061
Mailing address:
  • Phone: 804-220-2010
  • Fax: 804-299-4061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119008183
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: