Provider Demographics
NPI:1912483132
Name:DAVENPORT, KENNETH LANCE (APRN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LANCE
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 11TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SPRINGHILL
Mailing Address - State:LA
Mailing Address - Zip Code:71075-4503
Mailing Address - Country:US
Mailing Address - Phone:318-539-1701
Mailing Address - Fax:318-539-5688
Practice Address - Street 1:401 11TH ST NE
Practice Address - Street 2:
Practice Address - City:SPRINGHILL
Practice Address - State:LA
Practice Address - Zip Code:71075-4503
Practice Address - Country:US
Practice Address - Phone:318-539-1701
Practice Address - Fax:318-539-5688
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2477765Medicaid