Provider Demographics
NPI:1801469465
Name:DAVIS, DERRICKA A
Entity type:Individual
Prefix:MRS
First Name:DERRICKA
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REKA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6505 OLD BRANCH AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2603
Mailing Address - Country:US
Mailing Address - Phone:202-497-5454
Mailing Address - Fax:
Practice Address - Street 1:6505 OLD BRANCH AVE STE B1
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2603
Practice Address - Country:US
Practice Address - Phone:202-497-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date: