Basic Information
| Provider Information | |||||||||
| NPI: | 1730629163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TONYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGPCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 507 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727450507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136474100 | ||||||||
| FaxNumber: | 9136474120 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 SE 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727124900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799866199 | ||||||||
| FaxNumber: | 4796360371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2017 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0600X | AP133496 | TX | N | Nursing Service Providers | Registered Nurse | Gerontology | 363LG0600X | AP133496 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 236258758 | 05 | AR | MEDICAID | 420075835 | 05 | MO | MEDICAID | P02334973 | 01 | AR | RAILROAD | OTHER | 5E134 | 01 | AR | BCBS ARKANSAS | OTHER |