Provider Demographics
NPI:1003877630
Name:PORTER, CARLENE (APN)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 WEAVER PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3269
Mailing Address - Country:US
Mailing Address - Phone:630-352-5300
Mailing Address - Fax:630-352-5499
Practice Address - Street 1:4405 WEAVER PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3269
Practice Address - Country:US
Practice Address - Phone:630-352-5300
Practice Address - Fax:630-352-5499
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001548363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147104OtherMEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherRAILROAD MEDICARE PTAN (GROUP)
IL206147OtherMEDICARE PTAN (GROUP)
ILP01090259OtherRAILROAD MEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherRAILROAD MEDICARE PTAN (GROUP)
ILP01090259OtherRAILROAD MEDICARE PTAN (INDIVIDUAL)