Provider Demographics
NPI:1043047921
Name:DAVIDSON, CLARISSA YUVONNE
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:YUVONNE
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 1:9979 HIGHWAY 79
Mailing Address - Street 2:
Mailing Address - City:HAYNESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71038-4913
Mailing Address - Country:US
Mailing Address - Phone:318-624-6614
Mailing Address - Fax:
Practice Address - Street 1:5705 DIAZ AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5801
Practice Address - Country:US
Practice Address - Phone:318-624-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist