MEDICARE: NITA VIANN RANDOLPH DAVISON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1174934921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NITA VIANN RANDOLPH DAVISON

Provider Business Mailing Address
First Line	:	1889 S SYCAMORE ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-2730
Country	:	US
Telephone Number	:	804-605-9845
Fax Number	:	804-895-7853

Provider Business Practice Location Address
First Line	:	1889 S SYCAMORE ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-2730
Country	:	US
Telephone Number	:	804-605-9845
Fax Number	:	804-895-7853

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	11/14/2023

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