Provider Demographics
NPI:1134689326
Name:DAVIS, DESTINY S
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:S
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 1:405 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3524
Mailing Address - Country:US
Mailing Address - Phone:252-409-1203
Mailing Address - Fax:252-940-1206
Practice Address - Street 1:405 W 15TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3524
Practice Address - Country:US
Practice Address - Phone:252-409-1203
Practice Address - Fax:252-940-1206
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter