Provider Demographics
NPI:1285026880
Name:DAVIDSON, LISA ANN (CPNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 VENTURA DR
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1111
Mailing Address - Country:US
Mailing Address - Phone:253-312-7488
Mailing Address - Fax:
Practice Address - Street 1:1800 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7663
Practice Address - Country:US
Practice Address - Phone:360-337-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA95952163W00000X
WA60534425363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse