Provider Demographics
NPI:1164724787
Name:DAVIS, AMANDA NICOLE (CNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-992-0060
Mailing Address - Fax:740-446-5854
Practice Address - Street 1:280 PATTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9452
Practice Address - Country:US
Practice Address - Phone:740-395-8805
Practice Address - Fax:740-395-8855
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12007-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810019225Medicaid
OH000000691801OtherANTHEM BCBS
OH3108845Medicaid