Provider Demographics
NPI:1740648344
Name:DAVENPORT, CHARLISA
Entity type:Individual
Prefix:
First Name:CHARLISA
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLISA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7505 BEEBE DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:71033-3313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3095 WILSON CT
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-4945
Practice Address - Country:US
Practice Address - Phone:303-803-5726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA147386163W00000X
CO1636968163W00000X
LA208625363LP0808X
COC-APN.0003579-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse