1205836624 NPI number — MS. KELLI REBECCA PORTER W.H.N.P. - B.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205836624 NPI number — MS. KELLI REBECCA PORTER W.H.N.P. - B.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
KELLI
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
W.H.N.P. - B.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
KELLI
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
W.H.N.P. - B.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205836624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5656 BEE CAVES RD STE B101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LAKE HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78746-5281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-301-6767
Provider Business Mailing Address Fax Number:
512-301-6776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5656 BEE CAVES RD STE B101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST LAKE HILLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-301-6767
Provider Business Practice Location Address Fax Number:
512-301-6776
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SW0102X , with the licence number:  NCC ID# JON104317267 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN157053 . This is a "WH NURSE PRACTIONER LICEN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1529885 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80052 . This is a "PRESCRIPTIVE AUTHORITY#" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: P01155808 . This is a "MEDICARE RAILROAD PTAN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: AP04630 . This is a "LA STATE BOARD OF NURSING - ADVANCED PRACTICE REGISTERED NURSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 36958 . This is a "CDS LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 5H631DF29 . This is a "MEDICARE GROUPT#" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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