Provider Demographics
NPI:1730629163
Name:DAVIS, TONYA (AGPCNP)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0507
Mailing Address - Country:US
Mailing Address - Phone:913-647-4100
Mailing Address - Fax:913-647-4120
Practice Address - Street 1:3101 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4900
Practice Address - Country:US
Practice Address - Phone:479-986-6199
Practice Address - Fax:479-636-0371
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-05
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133496163WG0600X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR236258758Medicaid
MO420075835Medicaid
ARP02334973OtherRAILROAD
AR5E134OtherBCBS ARKANSAS