Provider Demographics
NPI:1861918344
Name:DAVENPORT, LISA MICHELE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 AVENUE O
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401-3924
Mailing Address - Country:US
Mailing Address - Phone:806-766-0273
Mailing Address - Fax:806-766-0250
Practice Address - Street 1:1950 ASPEN AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79404-1211
Practice Address - Country:US
Practice Address - Phone:806-740-1421
Practice Address - Fax:806-747-5491
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
283Q00000X, 261Q00000X
TXAP134875363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No283Q00000XHospitalsPsychiatric HospitalGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center