Provider Demographics
NPI:1932767928
Name:DAVIS, DIANE KELLY
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:KELLY
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 1:1126 SANDY POINT RD
Mailing Address - Street 2:
Mailing Address - City:HEATHSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22473-4494
Mailing Address - Country:US
Mailing Address - Phone:804-220-2010
Mailing Address - Fax:804-299-4061
Practice Address - Street 1:1026 JESSIE DUPONT MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:BURGESS
Practice Address - State:VA
Practice Address - Zip Code:22432-2038
Practice Address - Country:US
Practice Address - Phone:804-220-2010
Practice Address - Fax:804-299-4061
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008183225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist