Provider Demographics
NPI:1518927870
Name:DAVIS, THERESA (FNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1347 OZONE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:SALUDA
Practice Address - State:NC
Practice Address - Zip Code:28773-5506
Practice Address - Country:US
Practice Address - Phone:828-749-0149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2645A363L00000X
NC201054363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
189927OtherMEDCOST
SCNP1006Medicaid
S84215Medicare UPIN