MEDICARE: MADELYNE KAYE PORTER

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	225700000X	Massage Therapist	9505343-4701	UT
2	225700000X	Massage Therapist	148704	AK

General Provider Information

NPI Number	:	1336790146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELYNE KAYE PORTER

Provider Business Mailing Address
First Line	:	4339 S 2350 W
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-2013
Country	:	US
Telephone Number	:	757-771-6783
Fax Number	:

Provider Business Practice Location Address
First Line	:	5057 W 3450 S
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-8826
Country	:	US
Telephone Number	:	757-771-6783
Fax Number	:

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

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	11/20/2025

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