Provider Demographics
NPI:1912146648
Name:DAVENPORT, CANDICE L
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:L
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 1:1850 S AVENUE B APT 7C
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-5166
Mailing Address - Country:US
Mailing Address - Phone:928-580-6396
Mailing Address - Fax:
Practice Address - Street 1:1850 S AVENUE B APT 7C
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-5166
Practice Address - Country:US
Practice Address - Phone:928-580-6396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10556703747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider