Provider Demographics
NPI:1104368851
Name:PORTER, EDWARD JEROME (RN)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JEROME
Last Name:PORTER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 NW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34475-2645
Mailing Address - Country:US
Mailing Address - Phone:352-258-4015
Mailing Address - Fax:215-559-6336
Practice Address - Street 1:2925 NW 4TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34475-2645
Practice Address - Country:US
Practice Address - Phone:352-258-4015
Practice Address - Fax:215-559-6336
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-12
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
FL2681892163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679698296Medicaid
FL016981800Medicaid