Healthcare Provider Details

I. General information

NPI: 1962056283
Provider Name (Legal Business Name): THERESA T DAVIS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 HARBOURSIDE CENTRE LOOP
MIDLOTHIAN VA
23112-2170
US

IV. Provider business mailing address

6100 HARBOURSIDE CENTRE LOOP
MIDLOTHIAN VA
23112-2170
US

V. Phone/Fax

Practice location:
  • Phone: 804-639-7555
  • Fax:
Mailing address:
  • Phone: 804-639-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024177231
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: