Provider Demographics
NPI:1265551014
Name:DAVIS, CARLOTTA MARZOL (APRN)
Entity type:Individual
Prefix:
First Name:CARLOTTA
Middle Name:MARZOL
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
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 601964
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1964
Mailing Address - Country:US
Mailing Address - Phone:855-477-2477
Mailing Address - Fax:216-472-2740
Practice Address - Street 1:2351 AUGUSTA HWY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2213
Practice Address - Country:US
Practice Address - Phone:803-359-2486
Practice Address - Fax:803-359-4621
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1091363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2511Medicaid
SCS753217682Medicare PIN