Healthcare Provider Details

I. General information

NPI: 1821818402
Provider Name (Legal Business Name): SHAWNA DESPAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWNA DAVIDSON

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 ALLEN ST
KELSO WA
98626-4907
US

IV. Provider business mailing address

8 SCHONERT PL
LONGVIEW WA
98632-5616
US

V. Phone/Fax

Practice location:
  • Phone: 360-261-7020
  • Fax:
Mailing address:
  • Phone: 360-562-7971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: