Provider Demographics
NPI:1730808387
Name:DAVIDSON, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MASTERS RD
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3085
Mailing Address - Country:US
Mailing Address - Phone:423-505-7444
Mailing Address - Fax:
Practice Address - Street 1:109 MASTERS RD
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3085
Practice Address - Country:US
Practice Address - Phone:423-505-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6877235Z00000X
FLSA20592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist