Provider Demographics
NPI:1174934921
Name:DAVISON, NITA VIANN RANDOLPH
Entity type:Individual
Prefix:
First Name:NITA
Middle Name:VIANN RANDOLPH
Last Name:DAVISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NITA
Other - Middle Name:VIANN RANDOLPH
Other - Last Name:DAVISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1889 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2730
Mailing Address - Country:US
Mailing Address - Phone:804-605-9845
Mailing Address - Fax:804-895-7853
Practice Address - Street 1:1889 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2730
Practice Address - Country:US
Practice Address - Phone:804-605-9845
Practice Address - Fax:804-895-7853
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174934921Medicaid