Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 209-001548 | IL |
NPI | 1003877630 |
---|---|
Provider Name | Carlene Porter |
First Address | Warrenville, IL 60555-3269 |
Second Address | Warrenville, IL 60555-3269 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2006 |
Last Update Date | 29/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
206147 | MEDICARE PTAN (GROUP) (01) | IL |
206147104 | MEDICARE PTAN (INDIVIDUAL) (01) | IL |
CA4748 | RAILROAD MEDICARE PTAN (GROUP) (01) | IL |
P01090259 | RAILROAD MEDICARE PTAN (INDIVIDUAL) (01) | IL |
S71225 | (02) | IL |