Provider Demographics
NPI:1659716546
Name:PORTER-BEMPONG, FANISHA Y (MD)
Entity Type:Individual
Prefix:
First Name:FANISHA
Middle Name:Y
Last Name:PORTER-BEMPONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FANISHA
Other - Middle Name:Y
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34700 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4500
Mailing Address - Country:US
Mailing Address - Phone:262-646-4411
Mailing Address - Fax:262-646-1049
Practice Address - Street 1:50 GLENLAKE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3488
Practice Address - Country:US
Practice Address - Phone:800-767-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA826832084P0800X, 2084F0202X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry