Basic Information
| Provider Information | |||||||||
| NPI: | 1871058008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | ANGELINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 SHIPLEY ST APT 1404 | ||||||||
| Address2: | |||||||||
| City: | LADSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294564173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043395260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2019 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 124554 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.