Provider Demographics
NPI:1770258758
Name:DAVENPORT, BRANDI JO ANNA (LPN)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:JO ANNA
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LPN
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 38
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-0038
Mailing Address - Country:US
Mailing Address - Phone:423-442-3993
Mailing Address - Fax:423-442-9468
Practice Address - Street 1:3469 NEW HIGHWAY 68 STE A
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-5148
Practice Address - Country:US
Practice Address - Phone:423-442-3993
Practice Address - Fax:423-442-9468
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN084130164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse