1568962611 NPI number — TINA MARIE DAVIS FNP-BC

Table of content: TINA MARIE DAVIS FNP-BC (NPI 1568962611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568962611 NPI number — TINA MARIE DAVIS FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
TINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568962611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746079
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-733-9730
Provider Business Mailing Address Fax Number:
773-352-1513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 S BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-4214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-200-6707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1.032023 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 251990 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3015996 . This is a "KENTUCKY APRN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: APN.0993722 . This is a "AANC" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1032023 . This is a "TEXAS STATE LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2018032915 . This is a "MO STATE LICENSE NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0024181094 . This is a "VIRGINIA STATE LICENSE NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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