Provider Demographics
NPI:1366554149
Name:DAVIDSON, KATHLEEN ROSE (RNCS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 MANNING ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-3442
Mailing Address - Country:US
Mailing Address - Phone:781-444-1087
Mailing Address - Fax:
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:SUITE G05
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-893-8762
Practice Address - Fax:781-899-6386
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA117767 PC363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADA NS0511Medicare ID - Type Unspecified