Healthcare Provider Details

I. General information

NPI: 1588030134
Provider Name (Legal Business Name): KATHRYN DAVENPORT CORNELL A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W MYRTLE ST
INDEPENDENCE KS
67301-3317
US

IV. Provider business mailing address

800 W LAUREL ST
INDEPENDENCE KS
67301-3211
US

V. Phone/Fax

Practice location:
  • Phone: 620-577-4062
  • Fax: 620-577-4064
Mailing address:
  • Phone: 620-332-3280
  • Fax: 620-332-3281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-76887-072
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13-102368-072
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: