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General NPI Number Information
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NPI Number | 1942085832
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Entity Type | Organization
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Legal Business Name | MYRTLE DAVENPORT HEALTHCARE SERVICES LLC
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Dates
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Enumeration Date | 08/29/2023
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Last Update Date | 08/29/2023
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Provider Practice Location Address
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Address Line | 200 OXFORD LN
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City | FAYETTEVILLE
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State | GA
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Zip | 30215-5317
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Country | US
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Telephone | 678-203-4595
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Fax | 631-201-2695
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Provider Business Mailing Address
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Address Line | 200 OXFORD LN
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City | FAYETTEVILLE
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State | GA
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Zip | 30215-5317
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Country | US
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Telephone | 678-203-4595
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Fax | 631-201-2695
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Authorized Official
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Title or Position | NURSE PRACTITIONER/OWNER
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Name | MRS. MYRTLE HOWARD DAVENPORT
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Credential | APRN, NP-C, PMHNP-BC
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Telephone | 678-203-4595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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