Provider Demographics
NPI:1568962611
Name:DAVIS, TINA MARIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
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:PO BOX 746079
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6079
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-352-1513
Practice Address - Street 1:2115 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4214
Practice Address - Country:US
Practice Address - Phone:520-200-6707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1.032023363LF0000X
AZ251990363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3015996OtherKENTUCKY APRN
COAPN.0993722OtherAANC
TX1032023OtherTEXAS STATE LICENSE NUMBER
MO2018032915OtherMO STATE LICENSE NUMBER
VA0024181094OtherVIRGINIA STATE LICENSE NUMBER