Provider Demographics
NPI:1588137764
Name:DAVIDSON, LEANDRA LYNETTE (PMHNP)
Entity type:Individual
Prefix:
First Name:LEANDRA
Middle Name:LYNETTE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 ROUSE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-8324
Mailing Address - Country:US
Mailing Address - Phone:910-261-3481
Mailing Address - Fax:
Practice Address - Street 1:3201 ROUSE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-8324
Practice Address - Country:US
Practice Address - Phone:910-261-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2023-02-11
Deactivation Date:2023-01-28
Deactivation Code:
Reactivation Date:2023-02-11
Provider Licenses
StateLicense IDTaxonomies
NC255560163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1588137764OtherNPI
NC5013914OtherPMHNPLICENSE