Provider Demographics
NPI:1225648009
Name:DAVENPORT, ANGELA R (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 OLD FLORENCE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-8401
Mailing Address - Country:US
Mailing Address - Phone:931-762-6505
Mailing Address - Fax:
Practice Address - Street 1:1090 OLD FLORENCE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-8401
Practice Address - Country:US
Practice Address - Phone:931-762-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2021-06-25
Deactivation Date:2021-05-25
Deactivation Code:
Reactivation Date:2021-06-25
Provider Licenses
StateLicense IDTaxonomies
TN27979363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health