=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750788436
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELICA MARCIA DAVIS RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2014
-----------------------------------------------------
Last Update Date | 11/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 NC HWY 65
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-342-8316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3830 THORNABY CIR
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27107-1995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-624-9724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 173052
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------