Provider Demographics
NPI:1942872734
Name:MAJEKODUNMI, ANNETTE MARIE (FSS)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:MAJEKODUNMI
Suffix:
Gender:F
Credentials:FSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 NE MALLORY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3334
Mailing Address - Country:US
Mailing Address - Phone:971-263-3334
Mailing Address - Fax:
Practice Address - Street 1:4735 NE MALLORY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3334
Practice Address - Country:US
Practice Address - Phone:971-263-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000003469175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000003469OtherOREGON HEALTH AUTHORITY
ORTHW000003469OtherOREGON HEALTH AUTHORITY