Provider Demographics
NPI:1679111702
Name:DAVIS, DAMONIQUE
Entity type:Individual
Prefix:MS
First Name:DAMONIQUE
Middle Name:
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 1:2455 MANDEVILLE LN PH 12
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-6172
Mailing Address - Country:US
Mailing Address - Phone:210-710-2486
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-926-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC005177367500000X
TXAP144730367500000X
TX794301163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse