Basic Information
| Provider Information | |||||||||
| NPI: | 1730216052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | LUCY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APRN, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DRIVE, SUITE 300 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 FOUNDERS PLZ | ||||||||
| Address2: | SUITE 300 ATTN CREDENTIALING | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602824137 | ||||||||
| FaxNumber: | 8602820170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 000798 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 004199677 | 05 | CT | MEDICAID |