Provider Demographics
NPI:1508582552
Name:PORTER, QUANIESHA (IDD WAIVER SERVICES)
Entity Type:Individual
Prefix:
First Name:QUANIESHA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:IDD WAIVER SERVICES
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 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:
Practice Address - Street 1:710 OAK ST
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-3127
Practice Address - Country:US
Practice Address - Phone:601-394-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist