Provider Demographics
NPI:1083475073
Name:PORTER, LISA LYNN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 W VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4042
Mailing Address - Country:US
Mailing Address - Phone:712-541-3327
Mailing Address - Fax:
Practice Address - Street 1:1901 E BENNETT ST STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1427
Practice Address - Country:US
Practice Address - Phone:417-409-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program