Provider Demographics
NPI:1871058008
Name:DAVIS, ANGELINE MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:ANGELINE
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 SHIPLEY ST APT 1404
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4173
Mailing Address - Country:US
Mailing Address - Phone:804-339-5260
Mailing Address - Fax:
Practice Address - Street 1:2204 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1645
Practice Address - Country:US
Practice Address - Phone:434-517-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC124554367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered