Provider Demographics
NPI: | 1659831386 |
---|---|
Name: | DAVENPORT-WELTER, CHRISTINE EILEEN (MD, MPH) |
Entity Type: | Individual |
Prefix: | |
First Name: | CHRISTINE |
Middle Name: | EILEEN |
Last Name: | DAVENPORT-WELTER |
Suffix: | |
Gender: | F |
Credentials: | MD, MPH |
Other - Prefix: | |
Other - First Name: | CHRISTINE |
Other - Middle Name: | EILEEN |
Other - Last Name: | DAVENPORT |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 34703 |
Mailing Address - Street 2: | |
Mailing Address - City: | SEATTLE |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98124-1703 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 253-681-6626 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 17707 W MAIN ST FL 1 |
Practice Address - Street 2: | |
Practice Address - City: | MONROE |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98272-1967 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-282-7885 |
Practice Address - Fax: | 360-512-2026 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2019-03-20 |
Last Update Date: | 2023-12-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | 60956784 | 207Q00000X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 2134058 | Medicaid |