MEDICARE: MS. MARYELLEN ANN DAVISON RN

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	163WS0200X	School Registered Nurse	358624-1	NY

General Provider Information

NPI Number	:	1881968337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARYELLEN ANN DAVISON RN

Provider Business Mailing Address
First Line	:	140 BRIDGE ST
Second Line	:
City	:	CLEVELAND
State	:	NY
Zip	:	13042-3144
Country	:	US
Telephone Number	:	315-675-3172
Fax Number	:	315-675-3018

Provider Business Practice Location Address
First Line	:	140 BRIDGE ST
Second Line	:
City	:	CLEVELAND
State	:	NY
Zip	:	13042-3144
Country	:	US
Telephone Number	:	315-675-3172
Fax Number	:	315-675-3018

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

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	03/01/2012

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