Provider Demographics
NPI:1356894422
Name:PORTER, SHANNON LYNNE (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNNE
Last Name:PORTER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 VALLEY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5074
Mailing Address - Country:US
Mailing Address - Phone:855-984-5128
Mailing Address - Fax:
Practice Address - Street 1:20414 N 27TH AVE FL 4
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3250
Practice Address - Country:US
Practice Address - Phone:866-217-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60672144363L00000X, 363LF0000X
AZ279033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2065487Medicaid
WAG8958238Medicare PIN