Healthcare Provider Details

I. General information

NPI: 1265559009
Provider Name (Legal Business Name): MS. MARY GWEN DAVENPORT IX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMDT CG-1122 US COAST GUARD 2100 2ND ST SW, SUITE 5314
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

USCGC SEQUOIA WLB 215 VICTOR WHARF PIER THREE
FPO AP
96678 3922
US

V. Phone/Fax

Practice location:
  • Phone: 671-355-4885
  • Fax: 671-355-4928
Mailing address:
  • Phone: 671-355-4885
  • Fax: 3554928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: