Provider Demographics
NPI:1043440480
Name:DAVIDSON, CAROLYN FAY (RN, BSN, PMHNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:FAY
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:RN, BSN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10424 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4331
Mailing Address - Country:US
Mailing Address - Phone:414-774-1704
Mailing Address - Fax:414-873-1385
Practice Address - Street 1:10242 BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-301-7744
Practice Address - Fax:414-873-1385
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI110303-030163W00000X
WI6526-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse