Provider Demographics
NPI:1780103622
Name:DAVENPORT, KRISTINE (PT)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6437 PECAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-4123
Mailing Address - Country:US
Mailing Address - Phone:916-768-8265
Mailing Address - Fax:916-987-7104
Practice Address - Street 1:6437 PECAN AVE.
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-4123
Practice Address - Country:US
Practice Address - Phone:916-768-8265
Practice Address - Fax:916-987-7104
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist