Provider Demographics
NPI:1134341746
Name:PORTERA MANKINS, SALLY B (MD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:B
Last Name:PORTERA MANKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SALLY
Other - Middle Name:B
Other - Last Name:PORTERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 SAINT ELIZABETH BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1099
Mailing Address - Country:US
Mailing Address - Phone:618-234-2120
Mailing Address - Fax:618-641-5410
Practice Address - Street 1:211 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1915
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-641-5410
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36117761207L00000X
MO2009023911207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology