Individual
DIANE DAVISON
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
MT
Contact information
Practice address
29 MORNING ST, PORTLAND, ME 04101-4406
(207) 774-2822
Mailing address
29 MORNING ST, PORTLAND, ME 04101-4406
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MT247
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
060471
ANTHEM BLUE CROSS BLUE SH
ME
Enumeration date
05/19/2006
Last updated
07/08/2007
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