Provider Demographics
NPI:1528554722
Name:DAVIS, MARLESHIA TERRIAN
Entity Type:Individual
Prefix:
First Name:MARLESHIA
Middle Name:TERRIAN
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 1:319 POTTS RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3583
Mailing Address - Country:US
Mailing Address - Phone:229-256-8546
Mailing Address - Fax:
Practice Address - Street 1:319 POTTS RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3583
Practice Address - Country:US
Practice Address - Phone:229-256-8546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor