Healthcare Provider Details

I. General information

NPI: 1225648009
Provider Name (Legal Business Name): ANGELA R DAVENPORT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date: 05/25/2021
Reactivation Date: 06/25/2021

III. Provider practice location address

1090 OLD FLORENCE RD
LAWRENCEBURG TN
38464-8401
US

IV. Provider business mailing address

1090 OLD FLORENCE RD
LAWRENCEBURG TN
38464-8401
US

V. Phone/Fax

Practice location:
  • Phone: 931-762-6505
  • Fax:
Mailing address:
  • Phone: 931-762-6505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number27979
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: