Provider Demographics
NPI:1053376723
Name:DAVENPORT, MARION (ARNP)
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 S HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:321-725-5050
Mailing Address - Fax:321-725-9100
Practice Address - Street 1:720 E NEW HAVEN AVENUE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-724-4545
Practice Address - Fax:321-728-4168
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1415672363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303140300Medicaid
FLY7221ZMedicare ID - Type Unspecified
FL303140300Medicaid