Provider Demographics
NPI:1861150401
Name:DAVIS, KIM (NP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W PEELER AVE
Mailing Address - Street 2:
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38773-8710
Mailing Address - Country:US
Mailing Address - Phone:662-754-3301
Mailing Address - Fax:
Practice Address - Street 1:112 W PEELER AVE
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773-8710
Practice Address - Country:US
Practice Address - Phone:662-754-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine