Provider Demographics
NPI:1972893139
Name:DAVIS, MELANIE DAWN
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:DAWN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:DAWN
Other - Last Name:SULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:115 JUDGE GRESHAM RD
Practice Address - Street 2:SUITE B
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-6213
Practice Address - Country:US
Practice Address - Phone:423-477-2010
Practice Address - Fax:423-477-2161
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN15741363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350I9065Medicare PIN