Provider Demographics
NPI:1184473696
Name:PORTILLO, JOANNA STEPHANIE
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:STEPHANIE
Last Name:PORTILLO
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 1:9 SAINT PAUL ST STE 3
Mailing Address - Street 2:
Mailing Address - City:BOONSBORO
Mailing Address - State:MD
Mailing Address - Zip Code:21713-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 SAINT PAUL ST STE 3
Practice Address - Street 2:
Practice Address - City:BOONSBORO
Practice Address - State:MD
Practice Address - Zip Code:21713-1334
Practice Address - Country:US
Practice Address - Phone:301-432-6897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR233531163WM0705X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical