Provider Demographics
NPI:1245757244
Name:DAVIDSON, MARINNA ROSE
Entity type:Individual
Prefix:
First Name:MARINNA
Middle Name:ROSE
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 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8005
Mailing Address - Fax:
Practice Address - Street 1:11617 HEADLANDS TRL
Practice Address - Street 2:
Practice Address - City:SPENCERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46788
Practice Address - Country:US
Practice Address - Phone:260-515-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist