Healthcare Provider Details

I. General information

NPI: 1124946124
Provider Name (Legal Business Name): PRINCESS BENDJOUYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17911 NW EVERGREEN PL
BEAVERTON OR
97006-7438
US

IV. Provider business mailing address

1027 E BURNSIDE ST
PORTLAND OR
97214-1328
US

V. Phone/Fax

Practice location:
  • Phone: 503-239-8400
  • Fax:
Mailing address:
  • Phone: 503-239-8400
  • Fax: 503-239-8406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number25-CRM-4405
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: