Healthcare Provider Details

I. General information

NPI: 1780732479
Provider Name (Legal Business Name): SALLY MILLER DAVIDSON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 WAMPANOAG TRAIL SUITE 305
RIVERSIDE RI
02915
US

IV. Provider business mailing address

250 WAMPANOAG TRAIL SUITE 305
RIVERSIDE RI
02915
US

V. Phone/Fax

Practice location:
  • Phone: 401-270-4541
  • Fax: 401-270-4081
Mailing address:
  • Phone: 401-270-4541
  • Fax: 401-270-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN01050
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: