Provider Demographics
NPI:1962855692
Name:DAVENPORT, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37520 HARPER AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3077
Mailing Address - Country:US
Mailing Address - Phone:313-208-5882
Mailing Address - Fax:
Practice Address - Street 1:37520 HARPER AVE APT 107
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-3077
Practice Address - Country:US
Practice Address - Phone:313-208-5882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703011830164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse