Provider Demographics
NPI:1750831764
Name:DAVENPORT, BREANNA (MBA, VATL, ATC)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MBA, VATL, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10774 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:GLADE SPRING
Mailing Address - State:VA
Mailing Address - Zip Code:24340-5246
Mailing Address - Country:US
Mailing Address - Phone:276-206-6729
Mailing Address - Fax:
Practice Address - Street 1:812 THOMPSON DR
Practice Address - Street 2:C/O BRE DAVENPORT
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2346
Practice Address - Country:US
Practice Address - Phone:276-206-6729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260018322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer