Healthcare Provider Details

I. General information

NPI: 1629619770
Provider Name (Legal Business Name): LACONDA DAVENPORT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 S 6TH AVE
TUCSON AZ
85713-4701
US

IV. Provider business mailing address

PO BOX 746093
ATLANTA GA
30374-6093
US

V. Phone/Fax

Practice location:
  • Phone: 520-475-5418
  • Fax: 520-300-8034
Mailing address:
  • Phone: 520-475-5418
  • Fax: 520-300-8034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905253
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number222822
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number333031
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: