Healthcare Provider Details

I. General information

NPI: 1427595842
Provider Name (Legal Business Name): MACKENZIE DAVENPORT AT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6191 KRAFT AVE SE
GRAND RAPIDS MI
49512-9396
US

IV. Provider business mailing address

6130 WOODFIELD DR SE APT 2
GRAND RAPIDS MI
49548-8516
US

V. Phone/Fax

Practice location:
  • Phone: 616-871-6738
  • Fax:
Mailing address:
  • Phone: 574-274-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0002319
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003148A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002811
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: