Provider Demographics
NPI:1639799588
Name:DAVENPORT ADULT AND GERIATRIC WELLNESS
Entity Type:Organization
Organization Name:DAVENPORT ADULT AND GERIATRIC WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:804-564-6283
Mailing Address - Street 1:9536 ASHLEYVILLE TURN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-1690
Mailing Address - Country:US
Mailing Address - Phone:804-564-6283
Mailing Address - Fax:
Practice Address - Street 1:6701 COURTYARD RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1430
Practice Address - Country:US
Practice Address - Phone:804-564-6283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024169750OtherVIRGINIA STATE MEDICAL LICENSE