Provider Demographics
NPI:1659074532
Name:PORTER, KENZI BROOKE
Entity Type:Individual
Prefix:
First Name:KENZI
Middle Name:BROOKE
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 TRACE FRK
Mailing Address - Street 2:
Mailing Address - City:BRANCHLAND
Mailing Address - State:WV
Mailing Address - Zip Code:25506-6043
Mailing Address - Country:US
Mailing Address - Phone:681-347-8779
Mailing Address - Fax:
Practice Address - Street 1:2300 TRACE FRK
Practice Address - Street 2:
Practice Address - City:BRANCHLAND
Practice Address - State:WV
Practice Address - Zip Code:25506-6043
Practice Address - Country:US
Practice Address - Phone:681-347-8779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant