Healthcare Provider Details

I. General information

NPI: 1639755457
Provider Name (Legal Business Name): ALISA DAVIDOVA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WILLOW LN STE 201
ENGLISHTOWN NJ
07726-8434
US

IV. Provider business mailing address

187 ROUTE 36 STE 230
WEST LONG BRANCH NJ
07764-1306
US

V. Phone/Fax

Practice location:
  • Phone: 732-370-2220
  • Fax:
Mailing address:
  • Phone: 732-222-3805
  • Fax: 732-229-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ01096100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: