Provider Demographics
NPI:1922331354
Name:DAVENPORT, AMANDA C (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:C
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:C
Other - Last Name:STRECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 544
Mailing Address - Street 2:DEPT 5390
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-0544
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-8020
Practice Address - Street 1:9570 W 159TH ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5504
Practice Address - Country:US
Practice Address - Phone:708-675-7070
Practice Address - Fax:708-675-7074
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213992OtherGROUP PTAN
IL204591OtherGROUP PTAN