MEDICARE: MRS. CHARLENE DAVIS KING DNP, FPMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	R839684	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	455325	OTHER	MS	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104851161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHARLENE DAVIS KING DNP, FPMHNP-BC

Provider Business Mailing Address
First Line	:	713 FARMER ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2319
Country	:	US
Telephone Number	:	601-448-5176
Fax Number	:	601-448-5197

Provider Business Practice Location Address
First Line	:	713 FARMER ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2319
Country	:	US
Telephone Number	:	601-448-5176
Fax Number	:	601-448-5197

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	01/22/2016

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