Provider Demographics
NPI:1952965626
Name:WHITCHURCH, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WHITCHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-1357
Mailing Address - Country:US
Mailing Address - Phone:509-882-4700
Mailing Address - Fax:
Practice Address - Street 1:240 DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-1357
Practice Address - Country:US
Practice Address - Phone:509-882-4700
Practice Address - Fax:509-882-6088
Is Sole Proprietor?:No
Enumeration Date:2019-04-27
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61429360207Q00000X, 207Q00000X
ORMD208939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine