Provider Demographics
NPI:1376060962
Name:PORTER, KIMBERLY ANN PAULINE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN PAULINE
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 1:2007 SAW MILL RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5559
Mailing Address - Country:US
Mailing Address - Phone:904-652-4725
Mailing Address - Fax:
Practice Address - Street 1:1400 W STATE ST STE C
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-3438
Practice Address - Country:US
Practice Address - Phone:765-494-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28224750A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily