Healthcare Provider Details

I. General information

NPI: 1114471885
Provider Name (Legal Business Name): MILDRED MARIE PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2259 S WESTERN AVE APT 2
CHICAGO IL
60608-4476
US

IV. Provider business mailing address

14442 ABBOTTSFORD RD
MIDLOTHIAN IL
60445-2902
US

V. Phone/Fax

Practice location:
  • Phone: 312-738-3355
  • Fax:
Mailing address:
  • Phone: 708-371-7817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013926
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: