Provider Demographics
NPI:1508493883
Name:DAVIS, KATIE MARIE (MSN, CPNP-AC/PC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSN, CPNP-AC/PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 FOX BRIAR WAY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-6364
Mailing Address - Country:US
Mailing Address - Phone:804-205-8345
Mailing Address - Fax:
Practice Address - Street 1:5807 FOX BRIAR WAY
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-6364
Practice Address - Country:US
Practice Address - Phone:804-205-8345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA024179050208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty