Provider Demographics
NPI:1851028849
Name:PORTER, SANDRA (EP-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 LAUREN MARIE DR
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-2084
Mailing Address - Country:US
Mailing Address - Phone:404-925-2626
Mailing Address - Fax:
Practice Address - Street 1:200 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3473
Practice Address - Country:US
Practice Address - Phone:404-925-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA833754224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist