Provider Demographics
NPI:1932103546
Name:DAVIS, BRENDA (FNP)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 698
Mailing Address - Street 2:
Mailing Address - City:BYHALIA
Mailing Address - State:MS
Mailing Address - Zip Code:38611-0698
Mailing Address - Country:US
Mailing Address - Phone:662-838-2163
Mailing Address - Fax:662-838-7944
Practice Address - Street 1:12 EAST BRUNSWICK
Practice Address - Street 2:
Practice Address - City:BYHALIA
Practice Address - State:MS
Practice Address - Zip Code:38611
Practice Address - Country:US
Practice Address - Phone:662-838-2163
Practice Address - Fax:662-838-7944
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS81-0043363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123809Medicaid
S94558Medicare UPIN
MS500000843Medicare ID - Type Unspecified