Provider Demographics
NPI:1598545360
Name:DAVENPORT, COLIN DEANE
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:DEANE
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14471 DUBLIN DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-7760
Mailing Address - Country:US
Mailing Address - Phone:131-744-6938
Mailing Address - Fax:
Practice Address - Street 1:1716 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2173
Practice Address - Country:US
Practice Address - Phone:317-446-9383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28243621A163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice