Provider Demographics
NPI:1164169827
Name:PORTER, TAMIKA L
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:L
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 1:4137 SAUK TRL STE 153
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1253
Mailing Address - Country:US
Mailing Address - Phone:708-752-6620
Mailing Address - Fax:
Practice Address - Street 1:4137 SAUK TRL STE 153
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1253
Practice Address - Country:US
Practice Address - Phone:708-752-6620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-15
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL881739241Medicaid