1649460080 NPI number — TARA PATRICIA DAVIS RN, MSN, FNP-BC

Table of content: TARA PATRICIA DAVIS RN, MSN, FNP-BC (NPI 1649460080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649460080 NPI number — TARA PATRICIA DAVIS RN, MSN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
TARA
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649460080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 EAST MAIN STREET SUITE E #6 LEXINGTON, SC 29072
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29072-3440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-239-4660
Provider Business Mailing Address Fax Number:
803-233-4656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 KING LEES CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29072-7089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-239-4660
Provider Business Practice Location Address Fax Number:
803-233-4656
Provider Enumeration Date:
08/01/2007

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:  0024168713 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: RN274303 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 27964 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 024905300 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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