=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255567210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HYRUM DAVENPORT NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2009
-----------------------------------------------------
Last Update Date | 09/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4650 HAWTHORNE RD STE 3B
-----------------------------------------------------
City | CHUBBUCK
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83202-2376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-252-5621
-----------------------------------------------------
Fax | 208-648-4167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2516
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83206-2516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-252-5621
-----------------------------------------------------
Fax | 208-648-4167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | NP-913A
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------