Basic Information
| Provider Information | |||||||||
| NPI: | 1306584065 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | CHANNA | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5546 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753500 | ||||||||
| FaxNumber: | 8014753494 | ||||||||
| Practice Location | |||||||||
| Address1: | 3225 W GORDON AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840415728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013976150 | ||||||||
| FaxNumber: | 8013976151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2022 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19899-4405 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 198999-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.