=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386233781
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERMIKA SHANTE DAVIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2021
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 IVEY DR SW
-----------------------------------------------------
City | MILLEDGEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31061-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-251-4342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 IVEY DR SW
-----------------------------------------------------
City | MILLEDGEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31061-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-251-4342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number | CPB3556
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------