Provider Demographics
NPI:1326721507
Name:DAVIS, MARA
Entity Type:Individual
Prefix:
First Name:MARA
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 1:2511 OLD BAINBRIDGE RD APT A
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-3560
Mailing Address - Country:US
Mailing Address - Phone:850-692-4717
Mailing Address - Fax:
Practice Address - Street 1:2511 OLD BAINBRIDGE RD APT A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-3560
Practice Address - Country:US
Practice Address - Phone:850-692-4717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL131091637718091171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor