Provider Demographics
NPI:1952448953
Name:PORTER, DIANNE R (MSED)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:R
Last Name:PORTER
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 MARK DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5810
Mailing Address - Country:US
Mailing Address - Phone:631-567-5412
Mailing Address - Fax:
Practice Address - Street 1:11 WHITE BIRCH DR
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3827
Practice Address - Country:US
Practice Address - Phone:516-429-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor