Provider Demographics
NPI:1295245108
Name:BLEDSOE, DAVINA LYNN (FNP-BC)
Entity type:Individual
Prefix:
First Name:DAVINA
Middle Name:LYNN
Last Name:BLEDSOE
Suffix:
Gender:
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2100
Mailing Address - Country:US
Mailing Address - Phone:541-269-0333
Mailing Address - Fax:541-269-7389
Practice Address - Street 1:1750 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2195
Practice Address - Country:US
Practice Address - Phone:541-269-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201800261NP-PP363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500740413Medicaid