Healthcare Provider Details

I. General information

NPI: 1083158083
Provider Name (Legal Business Name): CINDY PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2016
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH STREET
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

PO BOX 40
SOUTHBRIDGE MA
01550-0040
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-909-7735
Mailing address:
  • Phone: 508-909-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2272633
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: