Provider Demographics
NPI:1932181005
Name:PORTE, KELLEEN ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:KELLEEN
Middle Name:ELIZABETH
Last Name:PORTE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 STOCKTON BLVD.
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817
Mailing Address - Country:US
Mailing Address - Phone:916-734-3888
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN294702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ23234Medicare UPIN
ZZZ303562Medicare ID - Type Unspecified