Provider Demographics
NPI:1619065596
Name:PORATH, RACHELLE KELLY (PT)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:KELLY
Last Name:PORATH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:
Practice Address - Street 1:2350 BENTRIDGE LN STE 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-0590
Practice Address - Country:US
Practice Address - Phone:910-339-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010799225100000X
NCP16594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650B110390OtherBCBS
MIP36780001Medicare PIN
MI650B110390OtherBCBS