Provider Demographics
NPI:1710504345
Name:DAVIS, TAQUINA CHANTE
Entity Type:Individual
Prefix:
First Name:TAQUINA
Middle Name:CHANTE
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 1:1289 HEINS RD
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-8924
Mailing Address - Country:US
Mailing Address - Phone:803-528-5090
Mailing Address - Fax:
Practice Address - Street 1:1501 SUMTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2829
Practice Address - Country:US
Practice Address - Phone:803-296-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC174H00000XMedicaid