Healthcare Provider Details

I. General information

NPI: 1205465986
Provider Name (Legal Business Name): DEJA DAVIS DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BURNETTS WAY STE 320
SUFFOLK VA
23434-8288
US

IV. Provider business mailing address

268 JONATHANS WAY
SUFFOLK VA
23434-9145
US

V. Phone/Fax

Practice location:
  • Phone: 757-934-1900
  • Fax: 757-925-6719
Mailing address:
  • Phone: 601-685-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024178059
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024178059
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: