Provider Demographics
NPI:1205836624
Name:PORTER, KELLI REBECCA (WHNP - BC)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:REBECCA
Last Name:PORTER
Suffix:
Gender:F
Credentials:WHNP - BC
Other - Prefix:MS
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP - BC
Mailing Address - Street 1:5656 BEE CAVES RD STE B101
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5281
Mailing Address - Country:US
Mailing Address - Phone:512-301-6767
Mailing Address - Fax:512-301-6776
Practice Address - Street 1:5656 BEE CAVES RD STE B101
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-301-6767
Practice Address - Fax:512-301-6776
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LANCC ID# JON104317267364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN157053OtherWH NURSE PRACTIONER LICEN
LA1529885Medicaid
LA80052OtherPRESCRIPTIVE AUTHORITY#
LAP01155808OtherMEDICARE RAILROAD PTAN
LAAP04630OtherLA STATE BOARD OF NURSING - ADVANCED PRACTICE REGISTERED NURSE
LA36958OtherCDS LICENSE
LA5H631DF29OtherMEDICARE GROUPT#
LA5H631DF29OtherMEDICARE GROUPT#
LAMP2012247OtherDEA LICENSE