Provider Demographics
NPI:1477712396
Name:PORTER, CLOIE DENITA
Entity Type:Individual
Prefix:
First Name:CLOIE
Middle Name:DENITA
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 1:2640 APPLEGATE RD
Mailing Address - Street 2:
Mailing Address - City:LUCAS
Mailing Address - State:OH
Mailing Address - Zip Code:44843-9718
Mailing Address - Country:US
Mailing Address - Phone:419-892-2895
Mailing Address - Fax:
Practice Address - Street 1:2640 APPLEGATE RD
Practice Address - Street 2:
Practice Address - City:LUCAS
Practice Address - State:OH
Practice Address - Zip Code:44843-9718
Practice Address - Country:US
Practice Address - Phone:419-892-2895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.111913164W00000X
OHPN. 111913164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse