Provider Demographics
NPI:1508193780
Name:DAVIS, TERESA YVETTE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:YVETTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 SILK POND DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7348
Mailing Address - Country:US
Mailing Address - Phone:704-502-3046
Mailing Address - Fax:
Practice Address - Street 1:206 S MATSON ST
Practice Address - Street 2:
Practice Address - City:KERSHAW
Practice Address - State:SC
Practice Address - Zip Code:29067-1506
Practice Address - Country:US
Practice Address - Phone:803-475-1156
Practice Address - Fax:803-475-1128
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4170363LF0000X
NCF0809225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA54788862Medicare PIN