Provider Demographics
NPI:1649703349
Name:PORTER, ERICA
Entity type:Individual
Prefix:MISS
First Name:ERICA
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 1:4760 E 68TH ST
Mailing Address - Street 2:APT267
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-4942
Mailing Address - Country:US
Mailing Address - Phone:918-565-2710
Mailing Address - Fax:
Practice Address - Street 1:4760 E 68TH ST
Practice Address - Street 2:#267
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-565-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKD999730843405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK006102757OtherSOONERCARE