Provider Demographics
NPI:1073284964
Name:PORTER, PORTIA MONIQUE (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:MONIQUE
Last Name:PORTER
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S GRACE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-5602
Mailing Address - Country:US
Mailing Address - Phone:252-407-8891
Mailing Address - Fax:
Practice Address - Street 1:7486 CREEDMOOR RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1663
Practice Address - Country:US
Practice Address - Phone:252-544-4369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No1744R1102XOther Service ProvidersSpecialistResearch Study
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1744P3200XMedicaid