Provider Demographics
NPI:1457820474
Name:DAVENPORT, SHILO L (LNP)
Entity Type:Individual
Prefix:
First Name:SHILO
Middle Name:L
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:LNP
Other - Prefix:
Other - First Name:SHILO
Other - Middle Name:L
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:QMHS
Mailing Address - Street 1:2000 NOBLE DR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-5353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2858 BACK ORRVILLE ROAD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9523
Practice Address - Country:US
Practice Address - Phone:330-264-3232
Practice Address - Fax:330-202-3897
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHLPN.135468.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator