MEDICARE: BRENDA DIANE PORCO-SMITH ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364S00000X	Clinical Nurse Specialist	352639	CA
2	363LF0000X	Family Nurse Practitioner	AP60194888	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104993179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA DIANE PORCO-SMITH ARNP

Provider Business Mailing Address
First Line	:	560 GAGE BLVD
Second Line	:	SUITE 203
City	:	RICHLAND
State	:	WA
Zip	:	99352
Country	:	US
Telephone Number	:	509-942-3627
Fax Number	:	509-942-2268

Provider Business Practice Location Address
First Line	:	6710 W OKANOGAN PLACE
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336
Country	:	US
Telephone Number	:	509-783-2000
Fax Number	:	509-783-2008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/06/2015

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