Provider Demographics
NPI:1083918197
Name:PORTER, MICHELLE M (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:PORTER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S 9TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 S 9TH ST
Practice Address - Street 2:6TH FLOOR WALNUT TOWERS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6810
Practice Address - Country:US
Practice Address - Phone:215-955-1925
Practice Address - Fax:215-928-3160
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004010133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102969883Medicaid
PA102969883Medicaid
NJ486371Medicare PIN