Provider Demographics
NPI:1790026607
Name:DAVENPORT, ERICA J (RD, LDN)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:J
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:RD, LDN
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 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7999
Mailing Address - Fax:508-909-7750
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-909-9771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAN02943133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered