Provider Demographics
NPI:1164574844
Name:DAVIS, MITRA MANSOURI (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MITRA
Middle Name:MANSOURI
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1100 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-252-1137
Mailing Address - Fax:404-252-6794
Practice Address - Street 1:1100 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 800
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1709
Practice Address - Country:US
Practice Address - Phone:404-252-1137
Practice Address - Fax:404-252-6794
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN112909367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife