Provider Demographics
NPI:1952844177
Name:DAVIS, ANGELA MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:844-362-1735
Practice Address - Fax:973-290-7495
Is Sole Proprietor?:No
Enumeration Date:2016-11-19
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015155363L00000X
IL209.015155363LF0000X
NJ26NJ00854700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209015155OtherSTATE LICENSE