Healthcare Provider Details

I. General information

NPI: 1912597675
Provider Name (Legal Business Name): MCKENZIE BROOKE DAVIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 08/23/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 PERIMETER PARK DR
COOKEVILLE TN
38501-0922
US

IV. Provider business mailing address

800 E SPRING ST APT NN2
COOKEVILLE TN
38501-4508
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-0002
  • Fax: 931-528-1515
Mailing address:
  • Phone: 931-239-5239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA0000004507
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: