Provider Demographics
NPI:1073694717
Name:DAVENPORT, KATHY C (ARNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:C
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:ARNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1146
Mailing Address - Street 2:1609 N STRONG BLVD SUITE 300
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-1146
Mailing Address - Country:US
Mailing Address - Phone:918-423-3400
Mailing Address - Fax:918-420-5051
Practice Address - Street 1:1609 N STRONG BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-3881
Practice Address - Country:US
Practice Address - Phone:918-423-3400
Practice Address - Fax:918-420-5051
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0044227363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
444864239001OtherBLUE CROSS/BLUE SHIELD