Basic Information
| Provider Information | |||||||||
| NPI: | 1316382328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ADRIANA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1180 ERNEST W BARRETT PKWY NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301444534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783542273 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1180 ERNEST W BARRETT PKWY NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301444534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783542273 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2013 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 076327 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.