Healthcare Provider Details

I. General information

NPI: 1720972540
Provider Name (Legal Business Name): CHAD THOMAS DAVIS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 RIVER OAKS DR
FLOWOOD MS
39232-9553
US

IV. Provider business mailing address

254 RESERVOIR WAY
BRANDON MS
39047-6785
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-1030
  • Fax:
Mailing address:
  • Phone: 601-421-7923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907486
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: