Provider Demographics
NPI:1083202121
Name:DAVIS, MADONNA
Entity Type:Individual
Prefix:
First Name:MADONNA
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:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:BELINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26250-0092
Mailing Address - Country:US
Mailing Address - Phone:130-461-4947
Mailing Address - Fax:
Practice Address - Street 1:12 S CRIM AVE
Practice Address - Street 2:
Practice Address - City:BELINGTON
Practice Address - State:WV
Practice Address - Zip Code:26250-8345
Practice Address - Country:US
Practice Address - Phone:304-823-0223
Practice Address - Fax:304-823-3600
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator