Provider Demographics
NPI:1942085832
Name:MYRTLE DAVENPORT HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:MYRTLE DAVENPORT HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRTLE
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, NP-C, PMHNP-BC
Authorized Official - Phone:678-203-4595
Mailing Address - Street 1:200 OXFORD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-5317
Mailing Address - Country:US
Mailing Address - Phone:678-203-4595
Mailing Address - Fax:631-201-2695
Practice Address - Street 1:200 OXFORD LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-5317
Practice Address - Country:US
Practice Address - Phone:678-203-4595
Practice Address - Fax:631-201-2695
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYRTLE DAVENPORT HEALTHCARE SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty