Provider Demographics
NPI:1629282579
Name:PORTER, MARIAN RAE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:RAE
Last Name:PORTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:RAE
Other - Last Name:TICHOTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:111 3RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEVIS
Mailing Address - State:MN
Mailing Address - Zip Code:56467
Mailing Address - Country:US
Mailing Address - Phone:218-652-2247
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0545675164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse