Provider Demographics
NPI:1508393711
Name:MOSLEY, PORCHA
Entity Type:Individual
Prefix:
First Name:PORCHA
Middle Name:
Last Name:MOSLEY
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 1:1484 STRAITS DR STE 5
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-8718
Mailing Address - Country:US
Mailing Address - Phone:989-667-8740
Mailing Address - Fax:
Practice Address - Street 1:1484 STRAITS DR STE 5
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-8718
Practice Address - Country:US
Practice Address - Phone:989-667-8740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291470363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty