Provider Demographics
NPI:1710694393
Name:PORTER, TINA MARIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
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 1:22799 PICNIC CT APT 108
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4577
Mailing Address - Country:US
Mailing Address - Phone:313-598-0779
Mailing Address - Fax:
Practice Address - Street 1:22799 PICNIC CT APT 108
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-4577
Practice Address - Country:US
Practice Address - Phone:313-598-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Single Specialty