Provider Demographics
NPI:1326231317
Name:DAVIDSON, KERRI AMBER (PTA)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:AMBER
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-1743
Mailing Address - Country:US
Mailing Address - Phone:712-732-7725
Mailing Address - Fax:712-732-1275
Practice Address - Street 1:315 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1743
Practice Address - Country:US
Practice Address - Phone:712-732-7725
Practice Address - Fax:712-732-1275
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665141Medicaid
IA166514Medicare Oscar/Certification