Provider Demographics
NPI:1558057398
Name:DAVISSON, DIANN MICHELE (CHAPLAIN)
Entity Type:Individual
Prefix:
First Name:DIANN
Middle Name:MICHELE
Last Name:DAVISSON
Suffix:
Gender:F
Credentials:CHAPLAIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-1306
Mailing Address - Country:US
Mailing Address - Phone:714-273-9014
Mailing Address - Fax:
Practice Address - Street 1:1143 10TH ST
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-1306
Practice Address - Country:US
Practice Address - Phone:714-273-9014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty