Provider Demographics
NPI:1962625855
Name:DAVIDSON, JUDI CAROL (CDM, CPM)
Entity type:Individual
Prefix:MRS
First Name:JUDI
Middle Name:CAROL
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:CDM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 BROADVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8302
Mailing Address - Country:US
Mailing Address - Phone:907-373-3420
Mailing Address - Fax:907-376-7847
Practice Address - Street 1:2650 BROADVIEW AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8302
Practice Address - Country:US
Practice Address - Phone:907-373-3420
Practice Address - Fax:907-376-7847
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA10175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNM0010Medicaid
AKAA10OtherSTATE LICENSE NUMBER