Provider Demographics
NPI:1073359279
Name:DAVIS, TARA YASMINA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:YASMINA
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 1:13040 QUANDER CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-4540
Mailing Address - Country:US
Mailing Address - Phone:703-625-0835
Mailing Address - Fax:
Practice Address - Street 1:8003 FRANKLIN FARMS DR RM 102
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5107
Practice Address - Country:US
Practice Address - Phone:804-945-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019005457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist