Provider Demographics
NPI:1235273855
Name:PORTER, SHELLEY (LRD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E BROADWAY AVENUE
Mailing Address - Street 2:P.O. BOX 997
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0997
Mailing Address - Country:US
Mailing Address - Phone:701-530-7000
Mailing Address - Fax:701-530-8842
Practice Address - Street 1:900 E BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-530-7000
Practice Address - Fax:701-530-8842
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2010-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND28133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered