Provider Demographics
NPI:1578532040
Name:PORTER, BRANDY KAY (ND)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:KAY
Last Name:PORTER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:MS
Other - First Name:BRANDY
Other - Middle Name:KAY
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ND
Mailing Address - Street 1:302 W FARIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-3005
Mailing Address - Country:US
Mailing Address - Phone:864-473-9406
Mailing Address - Fax:
Practice Address - Street 1:302 W FARIS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-3005
Practice Address - Country:US
Practice Address - Phone:864-473-9406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2163363LG0600X, 363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5004520OtherNC APRN
NC5004520OtherNC APRN
SCQ36653Medicare UPIN
SCAA07755770Medicare ID - Type Unspecified