Provider Demographics
NPI:1174256473
Name:PORTER, MALLORIE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:MALLORIE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 POTTS ST
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-8406
Mailing Address - Country:US
Mailing Address - Phone:704-997-9406
Mailing Address - Fax:704-896-4907
Practice Address - Street 1:522 POTTS ST
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8406
Practice Address - Country:US
Practice Address - Phone:704-997-9406
Practice Address - Fax:704-896-4907
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC255956163W00000X
NCL-306361163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC255956OtherRN
NCL-306361OtherIBCLC