Healthcare Provider Details

I. General information

NPI: 1740596998
Provider Name (Legal Business Name): AMBER L PORTER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4430 MISSOURI AVE BLDG 310
FORT LEONARD WOOD MO
65473
US

IV. Provider business mailing address

4430 MISSOURI AVE BLDG 310
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-1770
  • Fax: 573-596-1797
Mailing address:
  • Phone: 573-596-1770
  • Fax: 573-596-1797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2014018613
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: