Provider Demographics
NPI:1043613656
Name:DAVIDSON, MELISSA B
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
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 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-559-9337
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:207 SPARKS AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3739
Practice Address - Country:US
Practice Address - Phone:812-288-9141
Practice Address - Fax:812-288-1023
Is Sole Proprietor?:No
Enumeration Date:2014-09-28
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28160307A163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ446560OtherMEDICARE
IN201339720Medicaid