Provider Demographics
NPI:1588775605
Name:DAVIS, RITA-MARIE (CNM)
Entity type:Individual
Prefix:
First Name:RITA-MARIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 BURLEYSON RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3181
Mailing Address - Country:US
Mailing Address - Phone:706-278-4640
Mailing Address - Fax:706-275-6599
Practice Address - Street 1:1105 BURLEYSON RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3181
Practice Address - Country:US
Practice Address - Phone:706-278-4640
Practice Address - Fax:706-275-6599
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN136854367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA612318544AMedicaid