Basic Information
| Provider Information | |||||||||
| NPI: | 1558640417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOLAN | ||||||||
| OtherFirstName: | MINDY | ||||||||
| OtherMiddleName: | BETH | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 540 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT ANGEL | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973629540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038456841 | ||||||||
| FaxNumber: | 5038459229 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098972100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2011 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6529 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60503674 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.