Provider Demographics
NPI:1700409935
Name:PORTER, BRIANNA ALEXUS CHANTEA'
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:ALEXUS CHANTEA'
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 1:5108 CRABTREE PL
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3446
Mailing Address - Country:US
Mailing Address - Phone:757-292-7715
Mailing Address - Fax:
Practice Address - Street 1:5115 HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-0001
Practice Address - Country:US
Practice Address - Phone:757-683-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer