Healthcare Provider Details

I. General information

NPI: 1619377199
Provider Name (Legal Business Name): TIMOTHY G. DAVIS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TIM DAVIS FNP-C

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E COMMERCE ST
HERNANDO MS
38632-2302
US

IV. Provider business mailing address

429 E COMMERCE ST PMB 116
HERNANDO MS
38632-2348
US

V. Phone/Fax

Practice location:
  • Phone: 662-469-6000
  • Fax:
Mailing address:
  • Phone: 662-469-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number888378
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: