Provider Demographics
NPI:1912489261
Name:DAVIS, CASEY LYNN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 STUFFEL RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-6443
Mailing Address - Country:US
Mailing Address - Phone:423-748-5347
Mailing Address - Fax:
Practice Address - Street 1:208 SUNSET DR STE 340
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2521
Practice Address - Country:US
Practice Address - Phone:423-282-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000024487363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNAPN0000024487Medicaid