Healthcare Provider Details

I. General information

NPI: 1619556230
Provider Name (Legal Business Name): DALLAS JORDAN DAVIS PROVENCE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DALLAS JORDAN DAVIS NP

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 04/02/2021
Certification Date: 03/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6254 POPLAR AVE
MEMPHIS TN
38119-4713
US

IV. Provider business mailing address

295 PANDORA ST
MEMPHIS TN
38117-2854
US

V. Phone/Fax

Practice location:
  • Phone: 901-624-3333
  • Fax:
Mailing address:
  • Phone: 901-338-1340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number28973
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: