Provider Demographics
NPI:1932427671
Name:DAVIDSON, MIRIAM A (PNP)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:A
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9584
Mailing Address - Country:US
Mailing Address - Phone:970-347-2120
Mailing Address - Fax:970-346-9800
Practice Address - Street 1:350 CITY VIEW DR STE 302
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5307
Practice Address - Country:US
Practice Address - Phone:307-789-7915
Practice Address - Fax:307-789-7915
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY25621.1033RX363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY25621.1033RXOtherPSYCHIATRIC NURSE PRACTIONNER