Provider Demographics
NPI:1114193786
Name:DAVIDSON, MARY ANN (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 W ILLIANA DR
Mailing Address - Street 2:
Mailing Address - City:WEST TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47885-9006
Mailing Address - Country:US
Mailing Address - Phone:812-240-5108
Mailing Address - Fax:
Practice Address - Street 1:390 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3456
Practice Address - Country:US
Practice Address - Phone:321-633-3162
Practice Address - Fax:321-684-7872
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9448019363L00000X
IN71002633A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner