Provider Demographics
NPI:1356169296
Name:CLAYTON, PORSCHE
Entity type:Individual
Prefix:
First Name:PORSCHE
Middle Name:
Last Name:CLAYTON
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 1:122 W FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3561
Mailing Address - Country:US
Mailing Address - Phone:229-591-4000
Mailing Address - Fax:
Practice Address - Street 1:415 N JACKSON ST STE A
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3015
Practice Address - Country:US
Practice Address - Phone:229-591-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN104129164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse