Provider Demographics
NPI:1639755457
Name:DAVIDOVA, ALISA (APN)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:DAVIDOVA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 ROUTE 36 STE 230
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1306
Mailing Address - Country:US
Mailing Address - Phone:732-222-3805
Mailing Address - Fax:732-229-2060
Practice Address - Street 1:55 WILLOW LN STE 201
Practice Address - Street 2:
Practice Address - City:ENGLISHTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8434
Practice Address - Country:US
Practice Address - Phone:732-370-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01096100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner