Provider Demographics
NPI:1972842888
Name:PORTER, VICKIE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNN
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 RUST RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-1911
Mailing Address - Country:US
Mailing Address - Phone:901-353-0266
Mailing Address - Fax:
Practice Address - Street 1:6100 PRIMACY PKWY STE 112
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0705
Practice Address - Country:US
Practice Address - Phone:901-682-5335
Practice Address - Fax:901-682-5440
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000016856363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily