Provider Demographics
NPI:1942237409
Name:DAVIS, CAROLYN B (NP)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:D
Other - Last Name:KASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:131 WELTON WAY
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-360-4564
Mailing Address - Fax:704-360-4553
Practice Address - Street 1:131 WELTON WAY
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-360-4564
Practice Address - Fax:704-360-4553
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201516363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004074Medicaid
NCP69057Medicare UPIN
NCNC3717C566Medicare PIN