Provider Demographics
NPI:1255758504
Name:DAVIS, SHIRLEY T (RDN LD)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:T
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RDN LD
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:JUSTICE
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN LD
Mailing Address - Street 1:6856 COBBLESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9311
Mailing Address - Country:US
Mailing Address - Phone:888-416-0008
Mailing Address - Fax:888-416-0009
Practice Address - Street 1:6856 COBBLESTONE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9311
Practice Address - Country:US
Practice Address - Phone:888-416-0008
Practice Address - Fax:888-416-0009
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0054133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5735850001Medicare UPIN