Provider Demographics
NPI:1518940634
Name:DAVENPORT, LINDA J (MNT)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:J
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3441
Mailing Address - Country:US
Mailing Address - Phone:781-762-9010
Mailing Address - Fax:781-762-8067
Practice Address - Street 1:825 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3441
Practice Address - Country:US
Practice Address - Phone:781-762-9010
Practice Address - Fax:781-762-8067
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA142133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMT0143Medicare ID - Type Unspecified