Provider Demographics
NPI:1407467350
Name:PORTER, MIRANDA MARIE
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:MARIE
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 1:4760 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6335
Mailing Address - Country:US
Mailing Address - Phone:414-460-8392
Mailing Address - Fax:
Practice Address - Street 1:4760 N 22ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6335
Practice Address - Country:US
Practice Address - Phone:414-460-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management