MEDICARE: ABIGAIL U 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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1700417821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIGAIL U DAVIS

Provider Business Mailing Address
First Line	:	5113 GLEN CANYON RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-4104
Country	:	US
Telephone Number	:	817-879-9714
Fax Number	:

Provider Business Practice Location Address
First Line	:	5113 GLEN CANYON RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-4104
Country	:	US
Telephone Number	:	817-879-9714
Fax Number	:

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

Provider Enumeration Date	:	01/28/2020
Last Update Date	:	01/28/2020

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