Healthcare Provider Details

I. General information

NPI: 1811595150
Provider Name (Legal Business Name): LISA PORTER MS, HTL(ASCP)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 SIMMS ST
AURORA IL
60504-4359
US

IV. Provider business mailing address

1611 SIMMS ST
AURORA IL
60504-4359
US

V. Phone/Fax

Practice location:
  • Phone: 708-368-5055
  • Fax:
Mailing address:
  • Phone: 708-368-5055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QH0600X
TaxonomyHistology Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: