=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184107021
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL DAVIS DNP, CPNP-AC, CCRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2018
-----------------------------------------------------
Last Update Date | 03/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3701 CORRIERE RD STE 10
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18045-7991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-591-7205
-----------------------------------------------------
Fax | 484-591-7206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 LEAHY ST APT 224
-----------------------------------------------------
City | REDWOOD CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94061-3949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | SP020217
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------