Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LW0102X | Nurse Practitioner - Women's Health | 4704246721 | MI |
NPI | 1003297664 |
---|---|
Provider Name | Kimberly Porter |
First Address | Grand Rapids, MI 49503-2560 |
Second Address | Hastings, MI 49058-1729 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2015 |
Last Update Date | 29/11/2017 |