Provider Demographics
NPI:1063662419
Name:DAVIS, CHRISTY L (FNP)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:
Other - Last Name:BURRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1190 N STATE ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2413
Mailing Address - Country:US
Mailing Address - Phone:601-973-1624
Mailing Address - Fax:601-973-1596
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-973-1624
Practice Address - Fax:601-973-1596
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP322384164W00000X
MSR887871363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS463757YKHVMedicare PIN