MEDICARE: CHANAE LYNNETTE DAVIS

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	224P00000X	Prosthetist	1201137980	VA

General Provider Information

NPI Number	:	1639775976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANAE LYNNETTE DAVIS

Provider Business Mailing Address
First Line	:	609 WESTOVER HILLS BLVD APT B
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-4530
Country	:	US
Telephone Number	:	240-419-1914
Fax Number	:

Provider Business Practice Location Address
First Line	:	609 WESTOVER HILLS BLVD APT B
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-4530
Country	:	US
Telephone Number	:	240-419-1914
Fax Number	:

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

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	12/10/2020

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