Provider Demographics
NPI:1568832202
Name:DAVENPORT, CARLA MICHELLE (LAC)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:MICHELLE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E 154TH ST
Mailing Address - Street 2:3RD FLR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-2649
Mailing Address - Country:US
Mailing Address - Phone:310-309-0026
Mailing Address - Fax:
Practice Address - Street 1:207 E 94TH ST
Practice Address - Street 2:2ND FLR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3705
Practice Address - Country:US
Practice Address - Phone:310-309-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0055251171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist