Basic Information
| Provider Information | |||||||||
| NPI: | 1619314523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 749495 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303749495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662660555 | ||||||||
| FaxNumber: | 8662664999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1876 E SABIN DR STE 10 | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851226197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208369800 | ||||||||
| FaxNumber: | 5208361510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2013 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP4957 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP4957 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.