Provider Demographics
NPI:1265860605
Name:KELLIE DAVIDSON
Entity Type:Organization
Organization Name:KELLIE DAVIDSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:248-613-5082
Mailing Address - Street 1:1246 WEBER RD
Mailing Address - Street 2:1246 WEBER RD
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-9490
Mailing Address - Country:US
Mailing Address - Phone:248-613-5082
Mailing Address - Fax:
Practice Address - Street 1:1246 WEBER RD
Practice Address - Street 2:1246 WEBER RD
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-9490
Practice Address - Country:US
Practice Address - Phone:248-613-5082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.154534-M-IV251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care