Healthcare Provider Details

I. General information

NPI: 1912182130
Provider Name (Legal Business Name): TAMMY JEANNE DAVISON RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAMMY JEANNE CLARK

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 HUALAPAI MTN RD STE C
KINGMAN AZ
86401
UM

IV. Provider business mailing address

4099 GEMSTONE AVE
KINGMAN AZ
86401-7385
US

V. Phone/Fax

Practice location:
  • Phone: 928-415-0446
  • Fax: 928-692-1323
Mailing address:
  • Phone: 928-530-5430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number875166
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: