Provider Demographics
NPI:1134275076
Name:DAVENPORT, NANCY C
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:C
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 1:146 AN COUNTY ROAD 2405
Mailing Address - Street 2:
Mailing Address - City:MONTALBA
Mailing Address - State:TX
Mailing Address - Zip Code:75853-3220
Mailing Address - Country:US
Mailing Address - Phone:903-549-2155
Mailing Address - Fax:903-723-7378
Practice Address - Street 1:616 W RUSSELL PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX525853364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N8569OtherBLUE CROSS BLUE SHIELD
TXP00200022OtherRAIL ROAD
TXP00200022OtherRAIL ROAD