Provider Demographics
NPI:1558810432
Name:PORTER, VICKY (RD, LD)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 GREENSBORO WAY
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-5052
Mailing Address - Country:US
Mailing Address - Phone:860-402-6649
Mailing Address - Fax:
Practice Address - Street 1:434 GREENSBORO WAY
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-5052
Practice Address - Country:US
Practice Address - Phone:860-402-6649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 7604133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered