Provider Demographics
NPI:1821641168
Name:ANDERSON, DAVION (SUPPORTIVE CARE)
Entity Type:Individual
Prefix:
First Name:DAVION
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:SUPPORTIVE CARE
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 241654
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-9036
Mailing Address - Country:US
Mailing Address - Phone:414-551-2600
Mailing Address - Fax:
Practice Address - Street 1:8750 W MILL RD APT 25
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-1851
Practice Address - Country:US
Practice Address - Phone:414-551-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty