MEDICARE: MS. BETTY SUE DAVIDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	2506103	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2506103	OTHER	OH	PROVIDERNUMBER

General Provider Information

NPI Number	:	1477767358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETTY SUE DAVIDSON

Provider Business Mailing Address
First Line	:	4614 ANNAPOLIS AVE
Second Line	:	SAME
City	:	DAYTON
State	:	OH
Zip	:	45416-1543
Country	:	US
Telephone Number	:	937-559-0859
Fax Number	:

Provider Business Practice Location Address
First Line	:	4614 ANNAPOLIS AVE
Second Line	:	SAME
City	:	DAYTON
State	:	OH
Zip	:	45416-1543
Country	:	US
Telephone Number	:	937-559-0859
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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