Provider Demographics
NPI:1891159794
Name:PORTER, KEYONNA (NP)
Entity Type:Individual
Prefix:MRS
First Name:KEYONNA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:KEYONNA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7326
Practice Address - Country:US
Practice Address - Phone:843-212-8070
Practice Address - Fax:843-212-8071
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20196363L00000X, 363LF0000X
NM71593363LF0000X
SC204921390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program