MEDICARE: MS. KIMBERLI KEVIN DAVENPORT-HOLLADAY MS CCCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	22613	OR

General Provider Information

NPI Number	:	1770567562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLI KEVIN DAVENPORT-HOLLADAY MS CCCA

Provider Business Mailing Address
First Line	:	5620 SE LAMBERT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206
Country	:	US
Telephone Number	:	503-475-1266
Fax Number	:

Provider Business Practice Location Address
First Line	:	2860 SE HOLGATE BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-3658
Country	:	US
Telephone Number	:	503-234-7843
Fax Number	:	503-235-6973

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	07/08/2007

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