Provider Demographics
NPI:1134609704
Name:DAVIS, DAVID WAYNE
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 SW CULLEN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-3536
Mailing Address - Country:US
Mailing Address - Phone:386-497-1397
Mailing Address - Fax:
Practice Address - Street 1:238 SW CULLEN AVE
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-3536
Practice Address - Country:US
Practice Address - Phone:386-497-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9384698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily