Healthcare Provider Details

I. General information

NPI: 1407384787
Provider Name (Legal Business Name): RENITA DAVIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 WALNUT GROVE RD
MEMPHIS TN
38120-2113
US

IV. Provider business mailing address

1068 CRESTHAVEN RD STE 150
MEMPHIS TN
38119-3859
US

V. Phone/Fax

Practice location:
  • Phone: 901-227-9000
  • Fax:
Mailing address:
  • Phone: 901-682-6828
  • Fax: 901-682-9316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number137589
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number23068
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: