Provider Demographics
NPI:1962571554
Name:MASON DAVENPORT, KRISTI DAWN (PTA)
Entity type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:DAWN
Last Name:MASON DAVENPORT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 CUNNINGHAM FORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:TN
Mailing Address - Zip Code:38581-3032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:585 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3190
Practice Address - Country:US
Practice Address - Phone:931-723-7159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3883225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare ID - Type UnspecifiedGROUP #