Provider Demographics
NPI:1467931758
Name:PORNER, AMY DINEEN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DINEEN
Last Name:PORNER
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:PO BOX 23120
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-0420
Mailing Address - Country:US
Mailing Address - Phone:804-343-6500
Mailing Address - Fax:804-343-6515
Practice Address - Street 1:3820 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-4831
Practice Address - Country:US
Practice Address - Phone:804-343-6500
Practice Address - Fax:804-343-6515
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPGP-528920103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPGP-528920Medicaid