Provider Demographics
NPI:1740410661
Name:GOUGH-DAVIS, NORA CECELIA (FNP)
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:CECELIA
Last Name:GOUGH-DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W PEELER AVE
Mailing Address - Street 2:P.O. BOX 299
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38773-8710
Mailing Address - Country:US
Mailing Address - Phone:662-754-3301
Mailing Address - Fax:662-754-3304
Practice Address - Street 1:112 W PEELER AVE
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773-8710
Practice Address - Country:US
Practice Address - Phone:662-754-3301
Practice Address - Fax:662-754-3304
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872155363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09801514Medicaid
MS09801514Medicaid