Provider Demographics
NPI:1386020048
Name:DAVIS, BETTIEJOE
Entity type:Individual
Prefix:
First Name:BETTIEJOE
Middle Name:
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 1:5011 FLORAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-9153
Mailing Address - Country:US
Mailing Address - Phone:240-396-7662
Mailing Address - Fax:
Practice Address - Street 1:5011 FLORAL PARK RD
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-9153
Practice Address - Country:US
Practice Address - Phone:240-396-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16AL1132-A310400000X
MD171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility