Individual
TANJALA DAVENPORT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
811 W MARY ST APT B1, VALDOSTA, GA 31601-3781
(229) 630-5146
Mailing address
811 W MARY ST APT B1, VALDOSTA, GA 31601-3781
(229) 630-5146
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
—
Other
Enumeration date
10/18/2018
Last updated
10/18/2018
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