Provider Demographics
NPI:1427595842
Name:DAVENPORT, MACKENZIE (AT, ATC)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 WOODFIELD DR SE APT 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-8516
Mailing Address - Country:US
Mailing Address - Phone:574-274-6598
Mailing Address - Fax:
Practice Address - Street 1:6191 KRAFT AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-9396
Practice Address - Country:US
Practice Address - Phone:616-871-6738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00023192255A2300X
IN36003148A2255A2300X
MI26010028112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer