Healthcare Provider Details

I. General information

NPI: 1164548483
Provider Name (Legal Business Name): KATHRYN LOUISE DAVIDSON RNCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 REILLY ST
FORT BRAGG NC
28310-6600
US

IV. Provider business mailing address

2817 REILLY ST
FORT BRAGG NC
28310-7394
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8697
  • Fax: 910-907-8631
Mailing address:
  • Phone: 910-907-8697
  • Fax: 910-907-7463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number78142
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberDAV1-0430-4965
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: