Provider Demographics
NPI:1124536305
Name:DAVIDSON, RICHARD ISAAC (LPN)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ISAAC
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15675 AMBAUM BLVD SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2523
Mailing Address - Country:US
Mailing Address - Phone:206-631-3011
Mailing Address - Fax:206-631-3385
Practice Address - Street 1:22447 24TH AVE S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-7103
Practice Address - Country:US
Practice Address - Phone:206-631-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60598660164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse