Provider Demographics
NPI:1073003836
Name:DAVIS, KELLI ANN (DO)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PEDIATRIC OUTPATIENT CENTER
Mailing Address - Street 2:14 MEDICAL PARK, STE 400
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-6155
Mailing Address - Fax:803-434-6979
Practice Address - Street 1:PEDIATRIC OUTPATIENT CENTER
Practice Address - Street 2:14 MEDICAL PARK, STE 400
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6155
Practice Address - Fax:803-434-6979
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL51960208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics