Provider Demographics
NPI:1740653781
Name:DAVIS, AUDRA (NP-C)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 RIVERMIST RD
Mailing Address - Street 2:
Mailing Address - City:JULIETTE
Mailing Address - State:GA
Mailing Address - Zip Code:31046-3608
Mailing Address - Country:US
Mailing Address - Phone:478-476-1963
Mailing Address - Fax:
Practice Address - Street 1:402 OSIGIAN BLVD STE 400
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8992
Practice Address - Country:US
Practice Address - Phone:478-333-3058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN160065363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health