Provider Demographics
NPI:1184774473
Name:DAVIS, KIMBERLY A (CRNA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 POINT CLEAR DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8194
Mailing Address - Country:US
Mailing Address - Phone:228-831-0204
Mailing Address - Fax:228-831-1868
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 230A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-831-0204
Practice Address - Fax:228-831-1868
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR867487367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered