Provider Demographics
NPI:1871258830
Name:DAVIDSON, MCKENNA LARAE
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:LARAE
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 1:1650 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:IA
Mailing Address - Zip Code:50327-2326
Mailing Address - Country:US
Mailing Address - Phone:515-402-6750
Mailing Address - Fax:
Practice Address - Street 1:1200 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-1529
Practice Address - Country:US
Practice Address - Phone:515-263-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer