1265594618 NPI number — MRS. WHITNEY DIANE DAVIS PA-C

Table of content: MRS. WHITNEY DIANE DAVIS PA-C (NPI 1265594618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265594618 NPI number — MRS. WHITNEY DIANE DAVIS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
WHITNEY
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BARTLETT
Provider Other First Name:
WHITNEY
Provider Other Middle Name:
D.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265594618
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2514 WESLEY ST STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-1764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-282-2700
Provider Business Mailing Address Fax Number:
423-282-2802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2514 WESLEY ST STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-1764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-282-2700
Provider Business Practice Location Address Fax Number:
423-282-2802
Provider Enumeration Date:
12/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA0000002497 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0010-00630 . This is a "NC PA LICENSE INACTIVE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1265594618 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".