Provider Demographics
NPI:1760568398
Name:DAVIS, TEARSANEE CARLISLE (DNP, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TEARSANEE
Middle Name:CARLISLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-3992
Mailing Address - Fax:601-984-5583
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF FAMILY MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-2022
Practice Address - Fax:601-815-2036
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857403363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I500604OtherMEDICARE PTAN#
MS01888853Medicaid
MS302I508856Medicare PIN
MS512I500604OtherMEDICARE PTAN#