Provider Demographics
NPI:1255335295
Name:ANNOTTI, BRENDA R (FNP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:ANNOTTI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1196
Mailing Address - Country:US
Mailing Address - Phone:503-331-6440
Mailing Address - Fax:503-331-6445
Practice Address - Street 1:3550 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-331-6440
Practice Address - Fax:503-331-6445
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR091006966NI163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ANP0067OtherWORKERS COMPENSATION
OR292510Medicaid
OR292510Medicaid
ANP0067OtherWORKERS COMPENSATION