Provider Demographics
NPI:1902230451
Name:PORTER, HEIDI (RN)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-1793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1112 LOCUST ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-1793
Practice Address - Country:US
Practice Address - Phone:952-261-6481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-01
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 214080-3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse