Provider Demographics
NPI:1053862797
Name:DAVIDSON, JOHNETTA MARIE
Entity Type:Individual
Prefix:
First Name:JOHNETTA
Middle Name:MARIE
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 1:308 COMMERCIAL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3684
Mailing Address - Country:US
Mailing Address - Phone:912-352-2425
Mailing Address - Fax:912-352-4436
Practice Address - Street 1:308 COMMERCIAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3684
Practice Address - Country:US
Practice Address - Phone:912-352-2425
Practice Address - Fax:912-352-4436
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN073348164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse