Provider Demographics
NPI:1508533407
Name:DAVISON, DESIREE MARIE (CHA-T)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:MARIE
Last Name:DAVISON
Suffix:
Gender:F
Credentials:CHA-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 69
Mailing Address - Street 2:
Mailing Address - City:ELIM
Mailing Address - State:AK
Mailing Address - Zip Code:99739-0069
Mailing Address - Country:US
Mailing Address - Phone:907-890-3311
Mailing Address - Fax:907-890-2280
Practice Address - Street 1:1000 GREG KRUSHEK AVE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762-9976
Practice Address - Country:US
Practice Address - Phone:907-890-3311
Practice Address - Fax:907-890-2280
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA-TOtherCHA-T