Basic Information
| Provider Information | |||||||||
| NPI: | 1023025368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173668107 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3545 N VERMILION ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618321100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174428611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/13/2015 | ||||||||
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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 | 225100000X | 070-006853 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 279500 | 01 | IL | MEDICARE GROUP | OTHER | P00382789 | 01 | IL | RAILROAD MEDICARE | OTHER |