1184820128 NPI number — SHERRY ANNICE DAVIS NP-C

Table of content: SHERRY ANNICE DAVIS NP-C (NPI 1184820128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184820128 NPI number — SHERRY ANNICE DAVIS NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
SHERRY
Provider Middle Name:
ANNICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARWELL
Provider Other First Name:
SHERRY
Provider Other Middle Name:
ANNICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184820128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30503-0658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-718-1122
Provider Business Mailing Address Fax Number:
770-535-7445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 JESSE JEWELL PKWY SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-297-5700
Provider Business Practice Location Address Fax Number:
770-718-1877
Provider Enumeration Date:
06/26/2007

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: 363LF0000X , with the licence number:  RN050862 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WX0200X , with the licence number: RN050862 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: RN050862 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 315377424C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 315377424E . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1202662 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 03774175 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 315377424D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 315377424F . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 050862 . This is a "GNL" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 315377424C . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 315377424D . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 315377424F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 315377424E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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