Healthcare Provider Details

I. General information

NPI: 1568962611
Provider Name (Legal Business Name): TINA MARIE DAVIS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 ELON RD
MADISON HEIGHTS VA
24572-2536
US

IV. Provider business mailing address

134 ELON RD
MADISON HEIGHTS VA
24572-2536
US

V. Phone/Fax

Practice location:
  • Phone: 434-929-1400
  • Fax:
Mailing address:
  • Phone: 349-291-4004
  • Fax: 773-352-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number251990
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1.032023
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024181094
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: