Provider Demographics
NPI:1770317067
Name:DAVIDSON, KWINICA ANTONETTE (RN)
Entity type:Individual
Prefix:
First Name:KWINICA
Middle Name:ANTONETTE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 LAND O TREES ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-7404
Mailing Address - Country:US
Mailing Address - Phone:318-560-1702
Mailing Address - Fax:
Practice Address - Street 1:6120 LAND O TREES ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-7404
Practice Address - Country:US
Practice Address - Phone:318-560-1702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202890163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy