Provider Demographics
NPI:1508806308
Name:DAVIDSON, SUEANNE (NP)
Entity Type:Individual
Prefix:
First Name:SUEANNE
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MORDECAI
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:AL
Mailing Address - Zip Code:35447-0211
Mailing Address - Country:US
Mailing Address - Phone:205-399-1433
Mailing Address - Fax:
Practice Address - Street 1:108 5TH ST NE
Practice Address - Street 2:
Practice Address - City:ALICEVILLE
Practice Address - State:AL
Practice Address - Zip Code:35442-2200
Practice Address - Country:US
Practice Address - Phone:205-373-3945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-06250363L00000X
MSR865907363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS562251777OtherBLUE CROSS
MSP00191280OtherRAILROAD MEDICARE
MS08470589Medicaid