Healthcare Provider Details

I. General information

NPI: 1710440136
Provider Name (Legal Business Name): SADIE DAVENPORT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 02/17/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 TULLIE RD NE FL 3
ATLANTA GA
30329-2309
US

IV. Provider business mailing address

1400 TULLIE RD NE FL 3
ATLANTA GA
30329-2309
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax: 404-785-9111
Mailing address:
  • Phone: 404-785-5437
  • Fax: 404-785-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10552
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: