Provider Demographics
NPI:1710402979
Name:DAVENPORT, MYRTLE HOWARD (NP-C, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MYRTLE
Middle Name:HOWARD
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:NP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 DANNON VW SW
Mailing Address - Street 2:STE 3103
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2158
Mailing Address - Country:US
Mailing Address - Phone:404-549-9471
Mailing Address - Fax:404-549-9486
Practice Address - Street 1:831 FAIRWAYS CT
Practice Address - Street 2:STE #1
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:404-861-0827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN219619363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care