Provider Demographics
NPI:1053441881
Name:PORTER, JILL RENEE (CRNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:RENEE
Last Name:PORTER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 BELMONT AVE
Mailing Address - Street 2:STE 302
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-4506
Mailing Address - Country:US
Mailing Address - Phone:443-358-5388
Mailing Address - Fax:443-458-0661
Practice Address - Street 1:1310 BELMONT AVE
Practice Address - Street 2:STE 302
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-4506
Practice Address - Country:US
Practice Address - Phone:443-358-5388
Practice Address - Fax:443-458-0661
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR140131363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ19337Medicare UPIN
MD451M1466Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE