Provider Demographics
NPI:1912671272
Name:PORT, CASSIE L (FNP-C)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:L
Last Name:PORT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 S OLIVE PL
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6605
Mailing Address - Country:US
Mailing Address - Phone:801-837-7356
Mailing Address - Fax:
Practice Address - Street 1:3181 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5610
Practice Address - Country:US
Practice Address - Phone:801-352-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8325733-8900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner