Provider Demographics
NPI:1982262432
Name:DAVENPORT, CIARA A (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:
First Name:CIARA
Middle Name:A
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 GIBBS AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-1009
Mailing Address - Country:US
Mailing Address - Phone:234-348-9089
Mailing Address - Fax:
Practice Address - Street 1:809 GIBBS AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-1009
Practice Address - Country:US
Practice Address - Phone:234-348-9089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401072630410376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0329818Medicaid