Provider Demographics
NPI:1952842528
Name:PORTER, PHYLLIS DIANE
Entity Type:Individual
Prefix:MISS
First Name:PHYLLIS
Middle Name:DIANE
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:PO BOX 7064
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32238-0064
Mailing Address - Country:US
Mailing Address - Phone:904-444-3045
Mailing Address - Fax:
Practice Address - Street 1:6650 103RD ST
Practice Address - Street 2:APT 401
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7143
Practice Address - Country:US
Practice Address - Phone:904-559-5434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000809200251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000809200Medicaid