Provider Demographics
NPI:1639877640
Name:PORTER, LAURA (PMHNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7908 E PERALTA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-1561
Mailing Address - Country:US
Mailing Address - Phone:480-282-0197
Mailing Address - Fax:
Practice Address - Street 1:4001 E BASELINE RD STE 204
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2743
Practice Address - Country:US
Practice Address - Phone:480-565-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN159980163W00000X
AZ295354363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse