Provider Demographics
NPI:1487206306
Name:DAVENPORT, ANDREA LYNN (MS, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LYNN
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MS, FNP-BC
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:LYNN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4264 S 430 E
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:IN
Mailing Address - Zip Code:47952-8037
Mailing Address - Country:US
Mailing Address - Phone:765-376-2320
Mailing Address - Fax:
Practice Address - Street 1:703 W PARK ST
Practice Address - Street 2:
Practice Address - City:CAYUGA
Practice Address - State:IN
Practice Address - Zip Code:47928-8207
Practice Address - Country:US
Practice Address - Phone:765-492-9042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009111A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily