MEDICARE: MIKE S DAVENPORT FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.005569	IL
2	363L00000X	Nurse Practitioner	209.005569	IL

General Provider Information

NPI Number	:	1295789576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE S DAVENPORT FNP

Provider Business Mailing Address
First Line	:	206 S WASHINGTON ST
Second Line	:
City	:	MC LEANSBORO
State	:	IL
Zip	:	62859-1139
Country	:	US
Telephone Number	:	618-643-2835
Fax Number	:	618-643-2891

Provider Business Practice Location Address
First Line	:	206 S WASHINGTON ST
Second Line	:
City	:	MC LEANSBORO
State	:	IL
Zip	:	62859-1139
Country	:	US
Telephone Number	:	618-643-2835
Fax Number	:	618-643-2891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	04/22/2022

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