Provider Demographics
NPI:1356539654
Name:DAVIDSON, ELYSA R (LPN)
Entity type:Individual
Prefix:
First Name:ELYSA
Middle Name:R
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 BOARDWALK DR
Mailing Address - Street 2:N204
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-6226
Mailing Address - Country:US
Mailing Address - Phone:970-631-9486
Mailing Address - Fax:
Practice Address - Street 1:2345 BENT WAY
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7614
Practice Address - Country:US
Practice Address - Phone:303-678-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44461164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse