Provider Demographics
NPI:1619377199
Name:DAVIS, TIMOTHY G (FNP-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:DAVIS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:429 E COMMERCE ST
Mailing Address - Street 2:PMB 116
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2348
Mailing Address - Country:US
Mailing Address - Phone:662-469-6000
Mailing Address - Fax:
Practice Address - Street 1:116 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2302
Practice Address - Country:US
Practice Address - Phone:662-469-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS888378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily