Provider Demographics
NPI:1396112314
Name:DAVENPORT, SARA MICHELE (NP-C)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:MICHELE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13105 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3513
Mailing Address - Country:US
Mailing Address - Phone:310-915-7546
Mailing Address - Fax:
Practice Address - Street 1:13105 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3513
Practice Address - Country:US
Practice Address - Phone:310-915-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95002189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily