Individual
LARISSA DAVIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
200 DOCTORS DR, STE 201, DOUGLAS, GA 31533-2201
(912) 384-9460
(912) 393-1239
Mailing address
1100 WARD ST EXT W, DOUGLAS, GA 31534-1902
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
RN197160
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003145835A
—
GA
01
—
RN197160
MEDICAL LICENSE
GA
Enumeration date
04/22/2014
Last updated
09/06/2017
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