Provider Demographics
NPI:1336755099
Name:DAVIS, MACKENZIE FAITH
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:FAITH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:FAITH
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:741 PRESIDENT PL STE 210
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6809
Mailing Address - Country:US
Mailing Address - Phone:615-625-7780
Mailing Address - Fax:
Practice Address - Street 1:741 PRESIDENT PL STE 210
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6809
Practice Address - Country:US
Practice Address - Phone:615-625-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28196363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics