Basic Information
| Provider Information | |||||||||
| NPI: | 1962558700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTILLA | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | WHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24730 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372024730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153862300 | ||||||||
| FaxNumber: | 6153862399 | ||||||||
| Practice Location | |||||||||
| Address1: | 5201 CHARLOTTE PIKE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372093320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152221900 | ||||||||
| FaxNumber: | 6152221917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 02/03/2011 | ||||||||
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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 | 163WW0101X | 151993 | TN | N | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory | 363LW0102X | 12715 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 1521352 | 05 | TN | MEDICAID | 4279925 | 01 | TN | BCBST | OTHER |