Provider Demographics
NPI:1730131343
Name:DAVENPORT, DEANNA KATHLINE (APRN)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:KATHLINE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:APRN
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 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:1020 HITT ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-8788
Practice Address - Fax:573-882-3131
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO143086363L00000X, 363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO192693OtherBLUE SHIELD
MO192693OtherBLUE CHOICE
MO671689OtherHEALTHLINK
MO429268501Medicaid
MOP00150068Medicare PIN
MO819725236Medicare PIN
MO819721441Medicare PIN
MO192693OtherBLUE SHIELD
MOP00415555Medicare PIN