Healthcare Provider Details

I. General information

NPI: 1306297601
Provider Name (Legal Business Name): KELLIE DAVIDSON LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33187 SKYVIEW RD
WINCHESTER CA
92596-4524
US

IV. Provider business mailing address

33187 SKYVIEW RD
WINCHESTER CA
92596-4524
US

V. Phone/Fax

Practice location:
  • Phone: 248-613-5082
  • Fax:
Mailing address:
  • Phone: 248-613-5082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95197565
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number684225
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: