Provider Demographics
NPI:1619556230
Name:PROVENCE, DALLAS JORDAN DAVIS (NP)
Entity Type:Individual
Prefix:MRS
First Name:DALLAS
Middle Name:JORDAN DAVIS
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DALLAS
Other - Middle Name:JORDAN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:295 PANDORA ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-2854
Mailing Address - Country:US
Mailing Address - Phone:901-338-1340
Mailing Address - Fax:
Practice Address - Street 1:6254 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4713
Practice Address - Country:US
Practice Address - Phone:901-624-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28973207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology