Provider Demographics
NPI:1336805472
Name:PORTER, SHAILECE
Entity Type:Individual
Prefix:
First Name:SHAILECE
Middle Name:
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 1:104 SOUTH COSTELLO STREET
Mailing Address - Street 2:
Mailing Address - City:WALTHILL
Mailing Address - State:NE
Mailing Address - Zip Code:68067
Mailing Address - Country:US
Mailing Address - Phone:402-846-5533
Mailing Address - Fax:
Practice Address - Street 1:104 SOUTH COSTELLO STREET
Practice Address - Street 2:
Practice Address - City:WALTHILL
Practice Address - State:NE
Practice Address - Zip Code:68067
Practice Address - Country:US
Practice Address - Phone:402-846-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEH13858305175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist