1366481178 NPI number — MRS. PAMELA SUE PORTER APRN, MSN, FNP,BC

Table of content: MRS. PAMELA SUE PORTER APRN, MSN, FNP,BC (NPI 1366481178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366481178 NPI number — MRS. PAMELA SUE PORTER APRN, MSN, FNP,BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
PAMELA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, MSN, FNP,BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366481178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3322 LAGUNA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95616-4918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-923-2107
Provider Business Mailing Address Fax Number:
916-648-9131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9281 OFFICE PARK CIR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-8068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-691-5988
Provider Business Practice Location Address Fax Number:
916-691-6717
Provider Enumeration Date:
06/06/2006

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: 363LF0000X , with the licence number:  RN 445209 FNP 6259 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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