Provider Demographics
NPI:1942888227
Name:DAVENPORT, WENDELL
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 CONTACT ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-1939
Mailing Address - Country:US
Mailing Address - Phone:219-256-3052
Mailing Address - Fax:
Practice Address - Street 1:925 S SEMORAN BLVD STE 110A
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-5313
Practice Address - Country:US
Practice Address - Phone:888-830-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant