Provider Demographics
NPI:1932180106
Name:DAVIS, MARISSA K (CRNA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:K
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 PAVILION DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4657
Mailing Address - Country:US
Mailing Address - Phone:423-392-6343
Mailing Address - Fax:423-392-6159
Practice Address - Street 1:2204 PAVILION DR
Practice Address - Street 2:SUITE 105
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4657
Practice Address - Country:US
Practice Address - Phone:423-392-6343
Practice Address - Fax:423-392-6159
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000105257367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3635445Medicaid
KY0536404Medicare PIN
TN103I430019Medicare PIN