Provider Demographics
NPI:1710233838
Name:PORTER, AMANDA KATHLEEN (ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KATHLEEN
Last Name:PORTER
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 W MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-2864
Mailing Address - Country:US
Mailing Address - Phone:423-503-3229
Mailing Address - Fax:
Practice Address - Street 1:975 E 3RD ST # 376
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16873363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529239Medicaid