Provider Demographics
NPI:1083719272
Name:DAVENPORT, JUDITH A (CRNA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 N MACARTHUR BLVD
Mailing Address - Street 2:STE. 220
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2617
Mailing Address - Country:US
Mailing Address - Phone:972-714-0007
Mailing Address - Fax:972-714-0009
Practice Address - Street 1:5605 N MACARTHUR BLVD
Practice Address - Street 2:STE. 220
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2617
Practice Address - Country:US
Practice Address - Phone:972-714-0007
Practice Address - Fax:972-714-0009
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508432367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7419463831OtherTAX ID
TX83562UOtherBCBS
TX81143UOtherBCBS
TX83892UOtherBCBS
TX85385UOtherBCBS
TX88421COtherBCBS
TX089061804Medicaid
TX113718318OtherTAX ID
TX562365185OtherTAX ID
TX743018935OtherTAX ID NO
TX113718318OtherTAX ID
TX8B5026Medicare ID - Type UnspecifiedMEDICARE