Provider Demographics
NPI:1962824375
Name:DAVENPORT, ELISSA JO (NP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:JO
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:JO
Other - Last Name:STIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:8941 N RODGERS CT SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8013
Practice Address - Country:US
Practice Address - Phone:616-252-5300
Practice Address - Fax:616-252-5390
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260086363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704260086OtherSTATE LICENSE