Provider Demographics
NPI:1104851161
Name:KING, CHARLENE DAVIS (DNP, FPMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:DAVIS
Last Name:KING
Suffix:
Gender:F
Credentials:DNP, FPMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 FARMER ST
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-2319
Mailing Address - Country:US
Mailing Address - Phone:601-448-5176
Mailing Address - Fax:601-448-5197
Practice Address - Street 1:713 FARMER ST
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2319
Practice Address - Country:US
Practice Address - Phone:601-448-5176
Practice Address - Fax:601-448-5197
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR839684363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05207250Medicaid
MS455325OtherMEDICARE PTAN
MS455325OtherMEDICARE PTAN
MS500001647Medicare ID - Type Unspecified