Healthcare Provider Details

I. General information

NPI: 1740970854
Provider Name (Legal Business Name): AGNES E DAVENPORT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-491-6000
  • Fax: 317-491-6534
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013819A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: