MEDICARE: AGENA RENEE DAVENPORT-NICHOLSON MD

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	207V00000X	Obstetrics & Gynecology Physician	1026413	MA
2	207V00000X	Obstetrics & Gynecology Physician	67408	GA

General Provider Information

NPI Number	:	1710140330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGENA RENEE DAVENPORT-NICHOLSON MD

Provider Business Mailing Address
First Line	:	550 PEACHTREE ST NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-2212
Country	:	US
Telephone Number	:	404-727-8600
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 PEACHTREE ST NE
Second Line	:	MOT 8TH FLOOR
City	:	ATLANTA
State	:	GA
Zip	:	30308-2208
Country	:	US
Telephone Number	:	404-727-8600
Fax Number	:

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

Provider Enumeration Date	:	07/03/2008
Last Update Date	:	03/05/2026

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