Healthcare Provider Details

I. General information

NPI: 1235334723
Provider Name (Legal Business Name): RODEENA PORTER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNIOIN ST
LYNN MA
01901
US

IV. Provider business mailing address

PO BOX 526
LYNN MA
01903
US

V. Phone/Fax

Practice location:
  • Phone: 781-581-3900
  • Fax: 781-598-1050
Mailing address:
  • Phone: 781-596-2502
  • Fax: 781-596-3966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number110916
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: