Provider Demographics
NPI:1164720397
Name:DAVENPORT, KRISTY VICTORIA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:VICTORIA
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BOSTON POST RD
Mailing Address - Street 2:# 188
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-2402
Mailing Address - Country:US
Mailing Address - Phone:203-621-4773
Mailing Address - Fax:
Practice Address - Street 1:189 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1683
Practice Address - Country:US
Practice Address - Phone:203-621-4773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT082694163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse