Provider Demographics
NPI:1225631864
Name:DAVENPORT, TYRAYA
Entity Type:Individual
Prefix:
First Name:TYRAYA
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15235 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-1230
Mailing Address - Country:US
Mailing Address - Phone:216-203-0949
Mailing Address - Fax:
Practice Address - Street 1:15235 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-1230
Practice Address - Country:US
Practice Address - Phone:216-203-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172A00000X, 253Z00000X, 3747P1801X, 385HR2060X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No253Z00000XAgenciesIn Home Supportive Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1831678Medicaid