Provider Demographics
NPI:1437631330
Name:DAVIS, JUSTIN (ARNP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 7TH ST S STE 500
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4734
Mailing Address - Country:US
Mailing Address - Phone:727-893-6254
Mailing Address - Fax:727-553-7158
Practice Address - Street 1:603 7TH ST S STE 500
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4734
Practice Address - Country:US
Practice Address - Phone:727-893-6254
Practice Address - Fax:727-553-7158
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9304237363LF0000X
FLAPRN930437363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118693600Medicaid