Provider Demographics
NPI:1497040778
Name:DAVENPORT, MELISSA SUZANN (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUZANN
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 TRAMMEL RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-0778
Mailing Address - Country:US
Mailing Address - Phone:615-969-3375
Mailing Address - Fax:
Practice Address - Street 1:112 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TN
Practice Address - Zip Code:37030-1168
Practice Address - Country:US
Practice Address - Phone:615-735-0569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN02937225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant