Provider Demographics
NPI:1568591097
Name:NESMOE, DAVY L
Entity Type:Individual
Prefix:
First Name:DAVY
Middle Name:L
Last Name:NESMOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:BAUDETTE
Mailing Address - State:MN
Mailing Address - Zip Code:56623-1039
Mailing Address - Country:US
Mailing Address - Phone:218-634-3325
Mailing Address - Fax:
Practice Address - Street 1:204 MAIN AVE NORTH
Practice Address - Street 2:
Practice Address - City:BAUDETTE
Practice Address - State:MN
Practice Address - Zip Code:56623-1039
Practice Address - Country:US
Practice Address - Phone:218-634-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3C263NEOtherBLUE CROSS BLUE SHIELD