Basic Information
| Provider Information | |||||||||
| NPI: | 1104993179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORCO-SMITH | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 GAGE BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 6710 W OKANOGAN PLACE | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097832000 | ||||||||
| FaxNumber: | 5097832008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 352639 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 363LF0000X | AP60194888 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1104993179 | 05 | WA | MEDICAID |