Provider Demographics
NPI:1912182130
Name:DAVISON, TAMMY JEANNE (RD, CDE)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JEANNE
Last Name:DAVISON
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:JEANNE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4099 GEMSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-7385
Mailing Address - Country:US
Mailing Address - Phone:928-530-5430
Mailing Address - Fax:
Practice Address - Street 1:2535 HUALAPAI MTN RD
Practice Address - Street 2:STE C
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401
Practice Address - Country:UM
Practice Address - Phone:928-415-0446
Practice Address - Fax:928-692-1323
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ875166133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ168265OtherMEDICARE
AZ311096Medicaid
AZ120574Medicare PIN
AZ311096Medicaid