Provider Demographics
NPI:1205303021
Name:ANDERSON, IMANI
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:
Last Name:ANDERSON
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 1:17704 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6504
Mailing Address - Country:US
Mailing Address - Phone:503-919-5652
Mailing Address - Fax:
Practice Address - Street 1:434 NE ROSELAWN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3826
Practice Address - Country:US
Practice Address - Phone:503-919-5652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherDONT HAVE A NUMBER
OR0000Medicaid