Provider Demographics
NPI:1467400465
Name:DAVENPORT, ANDREA MICHELLE (LVN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MICHELLE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3744 GETTYSBURG ST
Mailing Address - Street 2:APT B
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1746
Mailing Address - Country:US
Mailing Address - Phone:760-380-7361
Mailing Address - Fax:
Practice Address - Street 1:BLDG 170 INNER LOOP
Practice Address - Street 2:ROOM 300
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-380-7361
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 183154164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse