Provider Demographics
NPI:1154516177
Name:DAVIDSON, NICKY R
Entity type:Individual
Prefix:MRS
First Name:NICKY
Middle Name:R
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:MCCUNE
Mailing Address - State:KS
Mailing Address - Zip Code:66753
Mailing Address - Country:US
Mailing Address - Phone:620-632-5154
Mailing Address - Fax:
Practice Address - Street 1:793 S 70TH ST
Practice Address - Street 2:
Practice Address - City:MCCUNE
Practice Address - State:KS
Practice Address - Zip Code:66753
Practice Address - Country:US
Practice Address - Phone:620-632-5154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies