=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790539286
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIMI LEA DAVIDSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2024
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8223 S. QUEBEC ST. SUIITE C
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-324-8789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8223 S. QUEBEC ST. SUIITE C
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F10230912
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 229329
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------