Healthcare Provider Details

I. General information

NPI: 1336194232
Provider Name (Legal Business Name): FREDERICK LENDEL DAVIDSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 LITTLE BIG HORN ST
FORT IRWIN CA
92310-1776
US

IV. Provider business mailing address

17 LITTLE BIG HORN ST
FORT IRWIN CA
92310-1776
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-5327
  • Fax: 760-380-5861
Mailing address:
  • Phone: 760-380-5327
  • Fax: 760-380-5861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN115554
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: