Provider Demographics
NPI:1740700889
Name:MILLS, DAVISA RENEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:DAVISA
Middle Name:RENEE
Last Name:MILLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DAVISA
Other - Middle Name:RENEE
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3401 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5103
Mailing Address - Country:US
Mailing Address - Phone:215-707-3008
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063381363A00000X, 363A00000X
NY020909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant