Provider Demographics
NPI:1609236504
Name:DAVIS, HENELLE (CSA, MSA)
Entity Type:Individual
Prefix:
First Name:HENELLE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CSA, MSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 VANTAGE DR.
Mailing Address - Street 2:APT 2072
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191
Mailing Address - Country:US
Mailing Address - Phone:704-614-0385
Mailing Address - Fax:
Practice Address - Street 1:2300 VANTAGE DR.
Practice Address - Street 2:APT 2072
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:704-614-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant