Basic Information
| Provider Information | |||||||||
| NPI: | 1023150455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 232 | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525182000 | ||||||||
| FaxNumber: | 3525675455 | ||||||||
| Practice Location | |||||||||
| Address1: | 10605 US HWY 301 | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525182000 | ||||||||
| FaxNumber: | 3525675455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN1161731 | FL | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.