Provider Demographics
NPI:1235789561
Name:DAVIDSON, RAEANN MAE
Entity Type:Individual
Prefix:
First Name:RAEANN
Middle Name:MAE
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 1:304 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MEDICINE LODGE
Mailing Address - State:KS
Mailing Address - Zip Code:67104-1425
Mailing Address - Country:US
Mailing Address - Phone:620-213-1193
Mailing Address - Fax:
Practice Address - Street 1:304 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MEDICINE LODGE
Practice Address - State:KS
Practice Address - Zip Code:67104-1425
Practice Address - Country:US
Practice Address - Phone:620-213-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider