Healthcare Provider Details

I. General information

NPI: 1063028744
Provider Name (Legal Business Name): MAKAYLA DAVIDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 S CENTRAL AVE
COLUMBUS OH
43223-1301
US

IV. Provider business mailing address

344 LAMBERT ST
GROVEPORT OH
43125-1365
US

V. Phone/Fax

Practice location:
  • Phone: 614-625-3092
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number463297
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: