Provider Demographics
NPI:1679189450
Name:DAVIDSON, KHADEJAH LESHAWNTE
Entity type:Individual
Prefix:
First Name:KHADEJAH
Middle Name:LESHAWNTE
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 1:1956 DRAPER AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-5323
Mailing Address - Country:US
Mailing Address - Phone:330-774-8241
Mailing Address - Fax:
Practice Address - Street 1:1956 DRAPER AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-5323
Practice Address - Country:US
Practice Address - Phone:330-774-8241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUD8360773747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty