MEDICARE: FANISHA Y PORTER-BEMPONG M.D.

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	2084P0800X	Psychiatry Physician	82683	GA
2	2084F0202X	Forensic Psychiatry Physician	82683	GA
3	2084P0804X	Child & Adolescent Psychiatry Physician	82683	GA

General Provider Information

NPI Number	:	1659716546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANISHA Y PORTER-BEMPONG M.D.

Provider Business Mailing Address
First Line	:	34700 VALLEY RD
Second Line	:
City	:	OCONOMOWOC
State	:	WI
Zip	:	53066-4500
Country	:	US
Telephone Number	:	262-646-4411
Fax Number	:	262-646-1049

Provider Business Practice Location Address
First Line	:	50 GLENLAKE PKWY STE 200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-3488
Country	:	US
Telephone Number	:	800-767-4411
Fax Number	:

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

Provider Enumeration Date	:	05/06/2013
Last Update Date	:	04/12/2023

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Directions to “ FANISHA Y PORTER-BEMPONG M.D.” Practice Location

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