Provider Demographics
NPI:1881866143
Name:DAVENPORT, BETTY JEAN (HOME HEALTH AID)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JEAN
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:HOME HEALTH AID
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 LIST ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2837
Mailing Address - Country:US
Mailing Address - Phone:330-837-7796
Mailing Address - Fax:
Practice Address - Street 1:3209 LIST ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-2837
Practice Address - Country:US
Practice Address - Phone:330-837-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2777786172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2777786OtherPROVIDER NUMBER