Provider Demographics
NPI:1386805885
Name:DAVIS, SHELLY DENICE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:DENICE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 LOVE AVENUE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794
Mailing Address - Country:US
Mailing Address - Phone:229-391-3300
Mailing Address - Fax:229-388-1948
Practice Address - Street 1:612 LOVE AVENUE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794
Practice Address - Country:US
Practice Address - Phone:229-391-3300
Practice Address - Fax:229-388-1948
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN089222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA481466728AMedicaid
GA5111500737Medicare PIN
GAQ46799Medicare UPIN
GA50BBJLCMedicare PIN