1053441881 NPI number — JILL RENEE PORTER CRNP

Table of content: JILL RENEE PORTER CRNP (NPI 1053441881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053441881 NPI number — JILL RENEE PORTER CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
JILL
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
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:
1053441881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 BELMONT AVE
Provider Second Line Business Mailing Address:
STE 302
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21804-4506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-358-5388
Provider Business Mailing Address Fax Number:
443-458-0661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 BELMONT AVE
Provider Second Line Business Practice Location Address:
STE 302
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21804-4506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-358-5388
Provider Business Practice Location Address Fax Number:
443-458-0661
Provider Enumeration Date:
03/07/2007

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:  R140131 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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