Provider Demographics
NPI:1578800397
Name:PORTER, KAILEIGH M (RD CDE)
Entity Type:Individual
Prefix:MS
First Name:KAILEIGH
Middle Name:M
Last Name:PORTER
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:MRS
Other - First Name:KAILEIGH
Other - Middle Name:M
Other - Last Name:DUYM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:905 UNION ST STE 11
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3039
Mailing Address - Country:US
Mailing Address - Phone:207-973-7334
Mailing Address - Fax:207-973-7424
Practice Address - Street 1:900 BROADWAY BLDG 3
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-907-1187
Practice Address - Fax:207-907-1189
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1186133V00000X
METD1145133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered