Provider Demographics
NPI:1407140478
Name:DAVIDSON, LEANN C (ARNP)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:C
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 BRICKYARD RD STE 5
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-6392
Mailing Address - Country:US
Mailing Address - Phone:850-415-6781
Mailing Address - Fax:850-415-6783
Practice Address - Street 1:1376 BRICKYARD RD STE 5
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-6392
Practice Address - Country:US
Practice Address - Phone:850-415-6781
Practice Address - Fax:850-415-6783
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3402062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005480000Medicaid
FLFA806YMedicare PIN