Healthcare Provider Details

I. General information

NPI: 1609396076
Provider Name (Legal Business Name): MELISSA J DAVIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 N JACKSON ST
BROOKHAVEN MS
39601
US

IV. Provider business mailing address

625 NEW HOPE TRL NW
BROOKHAVEN MS
39601-8622
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-3800
  • Fax:
Mailing address:
  • Phone: 601-754-9458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number894342
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number902135
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: