Provider Demographics
NPI:1114706520
Name:SONJU, AMANDA NICOLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:SONJU
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 1:5415 SW WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2409
Mailing Address - Country:US
Mailing Address - Phone:503-645-3581
Mailing Address - Fax:
Practice Address - Street 1:18417 SE OAK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-4850
Practice Address - Country:US
Practice Address - Phone:971-727-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program