Provider Demographics
NPI:1861850661
Name:BANASIAK, JANETTE J (762296)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:J
Last Name:BANASIAK
Suffix:
Gender:F
Credentials:762296
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 HEFFLEY ST S
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-9728
Mailing Address - Country:US
Mailing Address - Phone:503-983-8077
Mailing Address - Fax:
Practice Address - Street 1:422 HEFFLEY ST S
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361-9728
Practice Address - Country:US
Practice Address - Phone:503-983-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR762296171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor