Provider Demographics
NPI:1114068582
Name:DAVENPORT, MARY RAE (ANP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RAE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2748 CROSSROADS BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-3933
Mailing Address - Country:US
Mailing Address - Phone:970-255-0900
Mailing Address - Fax:970-255-0901
Practice Address - Street 1:2748 CROSSROADS BLVD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-3933
Practice Address - Country:US
Practice Address - Phone:970-255-0900
Practice Address - Fax:970-255-0901
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO75918363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health