Provider Demographics
NPI:1083288682
Name:AJAIFIA, MAURICE A (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:A
Last Name:AJAIFIA
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9605 GRAND RONDE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-9712
Mailing Address - Country:US
Mailing Address - Phone:503-879-2060
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61391953363LP0808X
OR10014932363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty