Provider Demographics
NPI:1609383967
Name:DAVIS, VANDELER (NP-C)
Entity Type:Individual
Prefix:
First Name:VANDELER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CHAMBLEE TUCKER RD BLDG 16
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4148
Mailing Address - Country:US
Mailing Address - Phone:770-939-1288
Mailing Address - Fax:707-212-2203
Practice Address - Street 1:2900 CHAMBLEE TUCKER RD BLDG 16
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4148
Practice Address - Country:US
Practice Address - Phone:770-939-1288
Practice Address - Fax:770-212-2203
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN183906363LG0600X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003231143AMedicaid