Provider Demographics
NPI:1386646198
Name:DAVIDSON, TERRA LYNN (RDLD)
Entity Type:Individual
Prefix:MRS
First Name:TERRA
Middle Name:LYNN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:LYNN
Other - Last Name:FRIELING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDLD
Mailing Address - Street 1:1804 BROWNING AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2302
Mailing Address - Country:US
Mailing Address - Phone:785-476-5430
Mailing Address - Fax:
Practice Address - Street 1:1823 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3381
Practice Address - Country:US
Practice Address - Phone:785-776-2886
Practice Address - Fax:785-565-4742
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1273133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q46318Medicare UPIN
130640Medicare ID - Type Unspecified