=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760145494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE G DAVIS NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2021
-----------------------------------------------------
Last Update Date | 10/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2639 GILMER AVE
-----------------------------------------------------
City | TALLASSEE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36078-7231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-283-3975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2214 WINDING OAK DR
-----------------------------------------------------
City | OPELIKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36804-0595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-618-8057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-129447
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------