Provider Demographics
NPI:1568832202
Name:DAVENPORT, CARLA MICHELLE (LAC)
Entity type:Individual
Prefix:MS
First Name:CARLA
Middle Name:MICHELLE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 KENTUCKY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2948
Mailing Address - Country:US
Mailing Address - Phone:913-286-8295
Mailing Address - Fax:
Practice Address - Street 1:1045 KENTUCKY ST APT 1
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2948
Practice Address - Country:US
Practice Address - Phone:913-286-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS23-00063171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist