Healthcare Provider Details

I. General information

NPI: 1639775976
Provider Name (Legal Business Name): CHANAE LYNNETTE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 WESTOVER HILLS BLVD APT B
RICHMOND VA
23225-4530
US

IV. Provider business mailing address

609 WESTOVER HILLS BLVD APT B
RICHMOND VA
23225-4530
US

V. Phone/Fax

Practice location:
  • Phone: 240-419-1914
  • Fax:
Mailing address:
  • Phone: 240-419-1914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1201137980
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: