Provider Demographics
NPI:1679888150
Name:PORTER, PAMELA DIANE (LPN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DIANE
Last Name:PORTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 S RACCOON RD
Mailing Address - Street 2:APT. A-44
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-3645
Mailing Address - Country:US
Mailing Address - Phone:330-261-9283
Mailing Address - Fax:
Practice Address - Street 1:446 S RACCOON RD
Practice Address - Street 2:APT. A-44
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-3645
Practice Address - Country:US
Practice Address - Phone:330-261-9283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN089708164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse