Provider Demographics
NPI:1407887334
Name:DAVENPORT, MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1587
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0587
Mailing Address - Country:US
Mailing Address - Phone:570-331-0880
Mailing Address - Fax:570-331-0220
Practice Address - Street 1:423 3RD AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5809
Practice Address - Country:US
Practice Address - Phone:570-331-0880
Practice Address - Fax:570-331-0220
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA043647367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
015192M49OtherMEDICARE ID
015192M49OtherMEDICARE ID
PA015192M49Medicare PIN
PA015192Medicare ID - Type Unspecified