Provider Demographics
NPI:1609333509
Name:PORTER, ESTACY (DNP, NP)
Entity Type:Individual
Prefix:
First Name:ESTACY
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:DNP, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-1421
Mailing Address - Country:US
Mailing Address - Phone:757-788-9578
Mailing Address - Fax:
Practice Address - Street 1:142 ALLEN DR
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-1421
Practice Address - Country:US
Practice Address - Phone:757-788-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-78383-111363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health