Provider Demographics
NPI:1861778276
Name:DAVENPORT-HERNANDEZ, NATALIE LORENE
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:LORENE
Last Name:DAVENPORT-HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:LORENE
Other - Last Name:DAVENPORT-HERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:3201 MC CLELLAND BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3502
Mailing Address - Country:US
Mailing Address - Phone:417-347-6625
Mailing Address - Fax:
Practice Address - Street 1:3201 MC CLELLAND BLVD STE A
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3502
Practice Address - Country:US
Practice Address - Phone:417-347-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-30
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011036227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily