Provider Demographics
NPI:1093883621
Name:DAVIDSON, TINA J (CNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:J
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2489 STELZER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-4007
Mailing Address - Country:US
Mailing Address - Phone:614-473-1300
Mailing Address - Fax:614-473-0722
Practice Address - Street 1:2489 STELZER RD STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-4007
Practice Address - Country:US
Practice Address - Phone:614-473-1300
Practice Address - Fax:614-473-0722
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.06617363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2508978Medicaid
OHDANP14554Medicare PIN
S86348Medicare UPIN