Provider Demographics
NPI:1376059907
Name:DAVIS, JOANNA BROOKE
Entity Type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:BROOKE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2411 HALFMOON LN
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-4374
Mailing Address - Country:US
Mailing Address - Phone:850-257-4766
Mailing Address - Fax:
Practice Address - Street 1:930 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-1706
Practice Address - Country:US
Practice Address - Phone:850-331-2987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15824235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497122725OtherTRICARE