Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 5012191 | NC |
NPI | 1003463969 |
---|---|
Provider Name | Brooke Alyssa Davis |
First Address | Charlotte, NC 28204-4319 |
Second Address | Charlotte, NC 28204-4319 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2019 |
Last Update Date | 04/09/2019 |