Provider Demographics
NPI:1053040949
Name:DAVISON, CASSANDRA
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:DAVISON
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 1:266 STATE HIGHWAY 184
Mailing Address - Street 2:
Mailing Address - City:HEUVELTON
Mailing Address - State:NY
Mailing Address - Zip Code:13654-3144
Mailing Address - Country:US
Mailing Address - Phone:315-528-7656
Mailing Address - Fax:
Practice Address - Street 1:214 KING ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1142
Practice Address - Country:US
Practice Address - Phone:315-713-5730
Practice Address - Fax:315-713-5389
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330512164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse