Provider Demographics
NPI:1407833221
Name:PORTER, WANDERFUL (FNP-BC)
Entity Type:Individual
Prefix:
First Name:WANDERFUL
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:E
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:602 BRUNSON DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4947
Mailing Address - Country:US
Mailing Address - Phone:662-680-3855
Mailing Address - Fax:662-680-3372
Practice Address - Street 1:602 BRUNSON DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4947
Practice Address - Country:US
Practice Address - Phone:662-680-3855
Practice Address - Fax:662-680-3372
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR748355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124068Medicaid
MS500001255Medicare PIN
MSP96374Medicare UPIN