Healthcare Provider Details

I. General information

NPI: 1528889599
Provider Name (Legal Business Name): EVELYN LORENE PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32377 US HIGHWAY 60
ELLSINORE MO
63937-8693
US

IV. Provider business mailing address

32377 US HIGHWAY 60
ELLSINORE MO
63937-8693
US

V. Phone/Fax

Practice location:
  • Phone: 573-323-2171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: