Provider Demographics
NPI:1396831061
Name:PORTER, KAREN ANNE (PT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANNE
Last Name:PORTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CREEKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-5891
Mailing Address - Country:US
Mailing Address - Phone:262-215-4551
Mailing Address - Fax:
Practice Address - Street 1:909 EAGLES LANDING PKWY STE 430
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6398
Practice Address - Country:US
Practice Address - Phone:770-506-6993
Practice Address - Fax:770-506-6994
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4381-024225100000X
GAPT011776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI392039073012OtherBLUE CROSS/BLUE SHIELD ID
WI000086007Medicare ID - Type UnspecifiedMEDICARE ID