Provider Demographics
NPI:1225314644
Name:PORTER, DESIRAE LATOYA (LPN)
Entity Type:Individual
Prefix:MS
First Name:DESIRAE
Middle Name:LATOYA
Last Name:PORTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 SHERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1110
Mailing Address - Country:US
Mailing Address - Phone:585-939-4428
Mailing Address - Fax:
Practice Address - Street 1:58 SHERWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1110
Practice Address - Country:US
Practice Address - Phone:585-939-4428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297558-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCOS 0602Medicaid
NYCOS 0264Medicaid
NYCOS 0267Medicaid
NYCOS 0265Medicaid