Provider Demographics
NPI:1508216953
Name:PORTER, LORI A
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
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 1:1744 TREVINO CIR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-6607
Mailing Address - Country:US
Mailing Address - Phone:630-640-7735
Mailing Address - Fax:
Practice Address - Street 1:1744 TREVINO CIR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-6607
Practice Address - Country:US
Practice Address - Phone:630-640-7735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001896133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered