Basic Information
Provider Information | |||||||||
NPI: | 1063662419 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | CHRISTY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BURRELL | ||||||||
OtherFirstName: | CHRISTY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1190 N STATE ST | ||||||||
Address2: | SUITE 204 | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392022413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019731624 | ||||||||
FaxNumber: | 6019731596 | ||||||||
Practice Location | |||||||||
Address1: | 1190 N STATE ST | ||||||||
Address2: | SUITE 204 | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392022413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019731624 | ||||||||
FaxNumber: | 6019731596 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2008 | ||||||||
LastUpdateDate: | 10/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | P322384 | MS | N |   | Nursing Service Providers | Licensed Practical Nurse |   | 363LF0000X | R887871 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.