Provider Demographics
NPI:1528681939
Name:DAVIS, BREANNA JO
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:JO
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 CANN RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-6505
Mailing Address - Country:US
Mailing Address - Phone:864-940-6533
Mailing Address - Fax:
Practice Address - Street 1:5115 HAMPTON BOULEVARD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-0001
Practice Address - Country:US
Practice Address - Phone:757-683-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program