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 1:11 BAXTER BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1801
Mailing Address - Country:US
Mailing Address - Phone:603-883-0005
Mailing Address - Fax:
Practice Address - Street 1:11 BAXTER BLVD FL 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1801
Practice Address - Country:US
Practice Address - Phone:603-883-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP131085363LP0808X
WY25621.1033RX363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY25621.1033RXOtherPSYCHIATRIC NURSE PRACTIONNER