Provider Demographics
NPI:1538912209
Name:GROVE, MAJESTIC BRIANNE
Entity type:Individual
Prefix:
First Name:MAJESTIC
Middle Name:BRIANNE
Last Name:GROVE
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 1:4545 NE HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-9655
Mailing Address - Country:US
Mailing Address - Phone:541-624-4288
Mailing Address - Fax:
Practice Address - Street 1:4545 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9655
Practice Address - Country:US
Practice Address - Phone:541-624-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker