Provider Demographics
NPI:1063764835
Name:DAVIDSON, JAMIE ANN (CRNA)
Entity type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:ANN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:TREASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1536 CRESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1917
Mailing Address - Country:US
Mailing Address - Phone:574-360-2619
Mailing Address - Fax:
Practice Address - Street 1:1536 CRESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1917
Practice Address - Country:US
Practice Address - Phone:574-360-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28173970A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered