Provider Demographics
NPI:1942463567
Name:DAVIS, STANITIA W (DPM)
Entity Type:Individual
Prefix:DR
First Name:STANITIA
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 NORTH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2615
Mailing Address - Country:US
Mailing Address - Phone:601-366-0026
Mailing Address - Fax:601-366-0069
Practice Address - Street 1:953 NORTH ST
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2615
Practice Address - Country:US
Practice Address - Phone:601-366-0026
Practice Address - Fax:601-366-0069
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80207213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program