Provider Demographics
NPI:1952719791
Name:DAVIDSON, NICHOLLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLLE
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 DENSHIRE DR NW
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-8699
Mailing Address - Country:US
Mailing Address - Phone:330-936-0940
Mailing Address - Fax:
Practice Address - Street 1:812 DENSHIRE DR NW
Practice Address - Street 2:
Practice Address - City:CANAL FULTON
Practice Address - State:OH
Practice Address - Zip Code:44614-8699
Practice Address - Country:US
Practice Address - Phone:330-936-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5505172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker