Provider Demographics
NPI:1205443058
Name:DAVIS, CLINTON (APRN, PMHNP)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:APRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 HUNTERS CROSSING LN
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-5453
Mailing Address - Country:US
Mailing Address - Phone:423-341-4475
Mailing Address - Fax:
Practice Address - Street 1:1025 EXECUTIVE PARK BLVD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4620
Practice Address - Country:US
Practice Address - Phone:423-830-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28302363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health