Provider Demographics
NPI:1447246780
Name:DAVIS, DONICA J (PAC)
Entity type:Individual
Prefix:
First Name:DONICA
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:DONICA
Other - Middle Name:J
Other - Last Name:BRAVICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1930 BRANNAN RD.
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253
Mailing Address - Country:US
Mailing Address - Phone:678-284-4686
Mailing Address - Fax:
Practice Address - Street 1:1336 HWY 54 WEST BLDG 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-3211
Practice Address - Country:US
Practice Address - Phone:770-460-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1259363A00000X
GA7390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41924300Medicaid
WI41924300Medicaid