Provider Demographics
NPI:1659332385
Name:DAVIS, LAURIE DEANNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:DEANNE
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 1:1508 TOMBRAS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-2720
Mailing Address - Country:US
Mailing Address - Phone:423-867-4969
Mailing Address - Fax:423-867-4971
Practice Address - Street 1:1508 TOMBRAS AVE
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-2720
Practice Address - Country:US
Practice Address - Phone:423-867-4969
Practice Address - Fax:423-867-4971
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN07173363LF0000X
GA218675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA510329585AMedicaid
TN1507242Medicaid
TN4155074OtherBCBS - TENNESSEE
GA510329585AMedicaid
GA202I503349Medicare PIN
GA202I503349Medicare PIN