Provider Demographics
NPI:1770742066
Name:PORTER, KEEVIA Y (NP-C)
Entity type:Individual
Prefix:MRS
First Name:KEEVIA
Middle Name:Y
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5517 HERITAGE LAKE CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-7473
Mailing Address - Country:US
Mailing Address - Phone:901-643-1540
Mailing Address - Fax:901-398-2699
Practice Address - Street 1:920 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-8240
Practice Address - Country:US
Practice Address - Phone:901-448-6134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000013460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily