Provider Demographics
NPI:1639467525
Name:DAVIDSON, MARY RITA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RITA
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4023
Mailing Address - Country:US
Mailing Address - Phone:434-766-9844
Mailing Address - Fax:434-791-5342
Practice Address - Street 1:326 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4023
Practice Address - Country:US
Practice Address - Phone:434-766-9844
Practice Address - Fax:434-791-5342
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0001181955163WP0807X
VA0024167128363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1770653537Medicaid