Provider Demographics
NPI:1881114361
Name:PORTER, SHYTIA LINCOLE
Entity type:Individual
Prefix:
First Name:SHYTIA
Middle Name:LINCOLE
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 1:14706 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2462
Mailing Address - Country:US
Mailing Address - Phone:708-244-5131
Mailing Address - Fax:
Practice Address - Street 1:14706 AVALON AVE
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2462
Practice Address - Country:US
Practice Address - Phone:708-244-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6367-9281-940OtherDRIVER LICENSE