Provider Demographics
NPI:1649460080
Name:DAVIS, TARA PATRICIA (RN, MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:PATRICIA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:955 EAST MAIN STREET SUITE E #6 LEXINGTON, SC 29072
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-3440
Mailing Address - Country:US
Mailing Address - Phone:803-239-4660
Mailing Address - Fax:803-233-4656
Practice Address - Street 1:115 KING LEES CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7089
Practice Address - Country:US
Practice Address - Phone:803-239-4660
Practice Address - Fax:803-233-4656
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168713363LF0000X
GARN274303363LF0000X
SC27964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC024905300Medicaid