Provider Demographics
NPI:1568836815
Name:DAVIS, SHELBY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 MCDOWELL ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-4238
Mailing Address - Country:US
Mailing Address - Phone:601-372-1117
Mailing Address - Fax:601-373-3004
Practice Address - Street 1:2860 MCDOWELL ROAD EXT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4238
Practice Address - Country:US
Practice Address - Phone:601-372-1117
Practice Address - Fax:601-373-3004
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR883040363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health