Provider Demographics
NPI:1316546492
Name:DAVIS, AMANDA BROOKE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:BROOKE
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 1:426 THOROUGHBRED DR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-6367
Mailing Address - Country:US
Mailing Address - Phone:423-715-1845
Mailing Address - Fax:
Practice Address - Street 1:119 WHITE WATER DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:TN
Practice Address - Zip Code:37361-3645
Practice Address - Country:US
Practice Address - Phone:423-299-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28397363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care