Provider Demographics
NPI:1568962611
Name:DAVIS, TINA MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746093
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6093
Mailing Address - Country:US
Mailing Address - Phone:773-352-1517
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:3820 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3227
Practice Address - Country:US
Practice Address - Phone:520-200-6707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251990363LF0000X
COAPN.0993722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024181094OtherVIRGINIA STATE LICENSE NUMBER
TX1032023OtherTEXAS STATE LICENSE NUMBER
KY3015996OtherKENTUCKY APRN
MO2018032915OtherMO STATE LICENSE NUMBER
COAPN.0993722OtherAANC