Basic Information
| Provider Information | |||||||||
| NPI: | 1932427671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806319584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703472120 | ||||||||
| FaxNumber: | 9703469800 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 CITY VIEW DR STE 302 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829305307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077897915 | ||||||||
| FaxNumber: | 3077897915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2010 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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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 | 363LP0808X | 25621.1033RX | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 25621.1033RX | 01 | WY | PSYCHIATRIC NURSE PRACTIONNER | OTHER |