Provider Demographics
NPI:1710200688
Name:DAVIDSON, ANGELA JEAN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:JEAN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-3604
Mailing Address - Country:US
Mailing Address - Phone:812-471-9701
Mailing Address - Fax:
Practice Address - Street 1:1415 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-9301
Practice Address - Country:US
Practice Address - Phone:812-838-6554
Practice Address - Fax:812-838-9685
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000564A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant