Provider Demographics
NPI:1578954574
Name:DAVIS, ANDREA CHRISTIAN
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:CHRISTIAN
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 1:26 CONNS LAKE RD SE
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30147-1440
Mailing Address - Country:US
Mailing Address - Phone:706-331-1502
Mailing Address - Fax:
Practice Address - Street 1:26 CONNS LAKE RD SE
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:GA
Practice Address - Zip Code:30147-1440
Practice Address - Country:US
Practice Address - Phone:706-331-1502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer