Provider Demographics
NPI:1700486008
Name:DAVIS, RANDI DAWNIELLE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:DAWNIELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:DAWNIELLE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1112 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:ADAH
Mailing Address - State:PA
Mailing Address - Zip Code:15410-1130
Mailing Address - Country:US
Mailing Address - Phone:724-984-9835
Mailing Address - Fax:
Practice Address - Street 1:1543 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1306
Practice Address - Country:US
Practice Address - Phone:304-363-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV105753363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health