Provider Demographics
NPI:1407198336
Name:PORTER, VEDA EVETTE (RMA, RPT, CNA, AHI)
Entity Type:Individual
Prefix:MRS
First Name:VEDA
Middle Name:EVETTE
Last Name:PORTER
Suffix:
Gender:F
Credentials:RMA, RPT, CNA, AHI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 INTERLAKEN PASS
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-8033
Mailing Address - Country:US
Mailing Address - Phone:678-830-3245
Mailing Address - Fax:
Practice Address - Street 1:1535 INTERLAKEN PASS
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-8033
Practice Address - Country:US
Practice Address - Phone:678-830-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0000042636374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA46-0604945OtherLIMITED LIABILITY COMPANY EIN #