Provider Demographics
NPI:1790997898
Name:CHUSSIL, JANICE T (ANP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:T
Last Name:CHUSSIL
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9495 SW LOCUST ST
Mailing Address - Street 2:STE A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6683
Mailing Address - Country:US
Mailing Address - Phone:503-636-9011
Mailing Address - Fax:503-636-3952
Practice Address - Street 1:9495 SW LOCUST ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6683
Practice Address - Country:US
Practice Address - Phone:503-445-2200
Practice Address - Fax:503-445-2201
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR090007375N3ANP-PP174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
115031Medicare ID - Type Unspecified
ORP80774Medicare UPIN