Provider Demographics
NPI:1952081648
Name:DAVIS, ANGELIQUE MICHELLE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:MICHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 WILLOW BROOK AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1093
Mailing Address - Country:US
Mailing Address - Phone:347-613-2825
Mailing Address - Fax:
Practice Address - Street 1:4705 WILLOW BROOK AVE
Practice Address - Street 2:APT 6
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029
Practice Address - Country:US
Practice Address - Phone:215-309-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier