Provider Demographics
NPI:1831105451
Name:DAVIS, DEBORAH M (CNP)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:M
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:8613 MS HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-8917
Mailing Address - Country:US
Mailing Address - Phone:662-285-9460
Mailing Address - Fax:
Practice Address - Street 1:700 WOODLAND DRIVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967
Practice Address - Country:US
Practice Address - Phone:662-283-3060
Practice Address - Fax:662-283-3553
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR818696363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0121694Medicaid
MS500001433Medicare ID - Type UnspecifiedCAHABA
MS0121694Medicaid