Provider Demographics
NPI:1164048260
Name:DAVENPORT, KATHERINE ALEXIS (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ALEXIS
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 BLUE RD APT 8
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04259-6900
Mailing Address - Country:US
Mailing Address - Phone:207-944-3139
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7027
Practice Address - Country:US
Practice Address - Phone:207-795-8368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1539133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered