Provider Demographics
NPI:1588856959
Name:PORTER, ANN MICHELLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:MICHELLE
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MICHELLE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:766 LAKELAND DR
Practice Address - Street 2:A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4610
Practice Address - Country:US
Practice Address - Phone:601-368-3440
Practice Address - Fax:601-368-3441
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR822501207RI0200X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR822501OtherNURSING LICENSE
MS03258395Medicaid
MS0292891-22OtherBOARD CERTIFICATION
MS03258395Medicaid