Provider Demographics
NPI:1750609673
Name:DAVENPORT, ARTYOM NICHOLAS (LMP)
Entity type:Individual
Prefix:
First Name:ARTYOM
Middle Name:NICHOLAS
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-7006
Mailing Address - Country:US
Mailing Address - Phone:253-861-1044
Mailing Address - Fax:
Practice Address - Street 1:1100 STATION DR STE 241
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-9777
Practice Address - Country:US
Practice Address - Phone:253-861-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60112076225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist