Provider Demographics
NPI:1679944946
Name:DAVENPORT, LAURA BETH (FNP-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:520 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129297363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-007OtherTRICARE
TX8343NSOtherBCBS
TX352819204Medicaid
TX75-0818167-015OtherTRICARE
TX850NYOtherBCBS
TX75-2616977-129OtherTRICARE
TX8478NYOtherBCBS
TX352819201Medicaid
TX75-0818167-048OtherTRICARE
TX75-2616977-028OtherTR
TXP01707526OtherRAIL ROAD MEDICARE
TX352819202Medicaid
TX352819203Medicaid
TX75-2616977-002OtherTRICARE
TX75-2616977-118OtherTRICARE
TX75-0818167-022OtherTRICARE
TX75-0818167-044OtherTRICARE
TX75-1976930-005OtherTRICARE
TX75-2616977-023OtherTRIUCARE
TXP01569953OtherRAIL ROAD MEDICARE
TX75-2616977-001OtherTRICARE
TX8946NYOtherBCBS
TXP01707529OtherRAIL ROAD MEDICARE
TX75-2616977-007OtherTRICARE
TXP01707529OtherRAIL ROAD MEDICARE
TX352819204Medicaid
TX352819202Medicaid